Subjective Ax Flashcards
What would you do prior to commencing your subjective assessment?
Introduce yourself to the patient
Check patient’s details; ask them what they would prefer to be called
Obtain next of kin details, including a contact number
Gain informed consent for assessment and treatment
How would you plan your subjective assessment?
Presenting Complaint History of Presenting Condition Special Questions Past Medical History Drug History Social History Aggs/ Eases 24 hour pattern
What information would you want to include on the body chart (PC)?
Areas of pain, if more than 1 are they related, all areas that may cause referred pain should be checked, relevant spinal region (Cx/Thx for UL, Lx/SI for LL)
Type of pain: sharp, burning (nerve), deep, boring and poorly localised (bone), localised, but referred pain to other areas (joint), diffuse, aching and poorly localised, often referred to other areas (vascular), dull aching, poorly localised and referred to other areas (muscle)
Depth: deep (muscles) superficial (joint)
Frequency: constant - felt unremittingly for 24 hours, does not alter in intensity (malignancy), does vary in intensity (inflammatory); intermittent - mechanical disturbance such that forces sufficient to stimulate free nerve endings are producing pain which stops when the force is removed
Intensity/severity:
VAS,NPRS
Abnormal sensation:
paraesthesia (tingling, P&Ns,), anaesthesia (complete loss of sensation), hypoaesthesia (reduced touch sensation), hyperaesthesia (heightened perception to touch), allodynia (pain provoked by stimuli that are not normally painful), analgesia (absence of pain), hypalgesia (diminished sensitivity to pain), hyperalgesia (increased sensitivity to pain)
What further questions would you ask regarding symptoms?
SIN factor: high/mod/low will influence Ax and Rx, Severity, Irritability, Nature - acute (12 weeks), acuter better prognosis; mechanical (intermittent) VS inflammatory (constant); structure - myo(muscle), arthro(joint), neuro(nerve)-genic
Aggravating factors: movements, postures that increase symptoms, time scales, check common aggs such as squat, driving, stairs, severity on NPRS.
Easing factors: movements, postures that decrease symptoms, time scales, severity on NPRS, coping strategies (heat, ice, etc)
Daily pattern *: 24 hour cycle, am: effect of rest, rise: effect of WB, morning stiffness < 30 mins (OA, spinal conditions, tendinopathies), >30 mins (spondyloarthropathies); day/evening, activity (mechanical); night – wakes in night, is it due to pain, time to get to sleep (lacking sleep = chronic persistent pain), position, mattress, pillows
Characteristics of pain mechanisms
Nociceptive pain:
tends to be localised
predictable response to
Neuropathic pain:
Central sensitisation:
What can aggravating factors tell us
Indicate how difficult or easy it may be to reproduce the patient’s symptoms in physical Ax and the irritability
AGGs determined for every symptom to determine the effect of aggravating one symptom on the other as it helps confirm relationship between symptoms
The aggravating movement/posture can tell us the structures being stressed, indicating structures causing symptoms
Common AGGS for each joint
Shoulder Elbow Forearm Wrist/Hand Hip Knee Foot/ankle Cx Thx Lx SIJ Muscle Nerve
What does easing factors tell us
Indicates how difficult or easy to be to relieve patient symptoms in physical Ax and in treatment and gives indication of irritability
The effect of easing one symptom on other symptoms helps confirm relationship of symptoms
The easing movement/posture can tell us the structures being relieved, indicating structures causing symptoms
What does easing factors tell us
Indicates how difficult or easy to be to relieve patient symptoms in physical Ax and in treatment and gives indication of irritability
The effect of easing one symptom on other symptoms helps confirm relationship of symptoms
The easing movement/posture can tell us the structures being relieved, indicating structures causing symptoms
What do you want to find out from the HPC
Start with open question - What’s wrong? (patient beliefs)
When and how did it start (e.g. Gradual or sudden onset, did you do anything- injury?, Did anything change beforehand? more or less activity, different activities,)
Onset/Aetiology - (traumatic/sudden or slow, known or unknown cause)
Stage of condition - (Acute, Sub-acute or Chronic)
Mechanism of Injury (MOI)
What’s happened since it started? (worse/better/same, what’s been done with it)
○ Progression of the symptoms - (getting better, worse or staying same)
Previous treatments (outcome and patient experience)
Previous Investigations (and findings/beliefs) - do they understand the findings of the Ix
Previous problems (similar in nature)
What do you want to find out from the past medical history?
Previous incidents and injuries (cause, duration, recovery, treatments)
Investigations and results
Other medical conditions - THREADS
Allergies
What does THREADS stand for?
Thyroid Disorders Heart Problems Rheumatoid Arthritis Epilepsy Asthma or other Respiratory Problems Diabetes Surgery
What does THREADS stand for?
Thyroid Disorders Heart Problems Rheumatoid Arthritis Epilepsy Asthma or other Respiratory Problems Diabetes Surgery
What do you want to obtain from their drug history?
Regular medications – what they are for, when did they last take it, side effects, are they overdosing (referral to pharmacists, GP, medics etc)
Pain relief – frequency, if they manage their pain, timing
Steroids (OP, #) and Anticoagulants (risk of bleeding)
Other non-prescription ‘meds’, eg TENS, homeopathic meds etc
What would you ask in your social history? Why do you ask it?
Age
Employment status: full time/part time/voluntary, type of job, sedentary/active, full duties/light duties/restricted duties, how they are managing at work, how their symptoms change at work
Hobbies – are they able to do, aim to get back to, any active hobbies
ADLs – carers, any caring duties, stairs, getting washed and dressed, driving issues (duration, posture, activity, in/out of car)
Dependents
To establish how their pain and presenting complaint influences their life, the biopsychosocial approach to patients.
Relevant to onset & progression of condition & goal setting
