Subjective Examination Flashcards
calgary cambridge consultation model
initiating session gather info physical examination provide structure to consultation build relationship explain and plan closing the session
purpose of initiating session
establish rapport
reason for consult is identified
purpose of gathering info
find patients problem
understand patient
purpose of providing structure to the consultation
organisation
attend to flow
purpose of building a relationship
appropriate non verbal behaviour
develop rapport
involve patient
purpose of explaining and planning
provide right info
aid accurate recall and understanding
shared understanding - incorporate patient’s perspective
plan -shared decision making
closing session purpose
Forward planning
Ensuring appropriate point of closure
assessment - cyclical process
subjective examination
physical examination
treatment
repeat
purpose of subjective examination
more than getting patient’s history
hear their story
use structured format
small part of solving puzzle
aim of subjective examination
find source of issue
find severity
identify contributing factors
identify important items to assess in physical examination
contraindications/precautions in examination and treatment
identify red flags(serious pathology. e.g. undiagnosed fracture, inflammatory arthritis)
somatic structures
body not mind
referred pain
when pain manifests itself at a distance to the actual tissue source
more central the source, the more extensive possible area of referral
(someone experiences pain in one location but the source of the pain is in another location)
example of referred pain
posterior leg pain referred to the back
osteoarthritis - knee pain hip is referring pain to the neck
example of viscera referral
heart attack - shoots down the arm
kidney infection - manifests as back pain
viscera (internal organs)
spine
or spin refer to viscera
transmission of sensory info to spinal cord
receptor dorsal root ganglion (sensory neuron) association neuron in integrating centre motor neuron ventral root effector
Convergence-Projection Theory of Referral-Somatic structures example
hip and knee both converge at lumbar 2-3
brain does not where exactly pain is located
Convergence-Projection Theory of Referral-Somatic structures
sense from 2 different locations converge at the same time and brain cannot interpret where source of pain is
radicular pain
nerve root pain
comes from 1 or more spinal nerve root
radicular pain and referred pain difference
radicular pain - from spinal nerve root
referred pain - from somatic structure e.g. joint/muscle
dermatomes
An area of the skin supplied by nerves from a single spinal root.
Nerve Root is where nerves emerges from spinal cord
example of dermatomes
: pain in the thumb could be due to C6 nerve root emerging from spinal cord in neck
subjective exam overview
Reason for attendance Body chart Behaviour of Symptoms Special Questions History of Present Condition (HPC) Past Medical History (PMHx) Medications Social (Soc Hx) & Family History (FHx) Patient’s goals / expectations
what will be assessed in the body chart
current symptoms (swelling, pain etc.) map on body chart - for area tick symptom free area ask for depth (superficial or deep) or quality of pain frequency of pain - non stop (red flag), occasional, intermittent intensity abnormal sensation relationship of symptoms
Rating pain
Visual analogue scale (VAS)
NRS - Numerical Rating Scale (NRS)
To quantify pain
both reliable and valid
deep nagging dull pain is is found in
bone
dull ache pain is found in
muscle
Sharp, shooting pain is in
nerve root
Sharp, lightning-like pain is in
nerve
Burning, pressure-like, stinging, aching pain is in
Sympathetic Nerve
Throbbing, diffuse pain is in
Vascular
behaviour of pain
If more than pain - hierarchy, temporal relationship
24 Hour PATTERN - night pain - concerning
Aggravating factors
MECHANICAL-
Easing factors
examples of aggravating factors
activities/positions
how quick to come on and ease
severe enough to stop activity
easing factor examples
activities/position
drugs
heat
cold
OTHER Behaviour symptoms
stiffness weakness locking clicks crepitus (grating) parasthesia numbness swelling
serious red flags
Severe, unremitting pain
Night Pain
ways to investigate red flags
X-ray, MRI, CT scan, US, bone scan
red flag pathologies
Inflammatory disorders RA, AS Spinal Cord compression Fracture Cancer (primary or secondary) Infections (bone, joint etc)
HPc
History of present complaitn
history of present complaint (HPc)
onset - sudden (traumatic or non trauamtic)
gradual (past trauma, trigger)
sequence of symptoms
MOI (Mechanism of Injury)
Stability: worsening, improving, ISQ (In Status Quo)
Work / Sport participation
PMHx
Past Medical History
Past Medical History
past similar episodes – explore - recurrency, rate past episode, recovery
Past medical (or surgical hx) – surgeries, broken bones, hospitalisation
Ongoing Medical conditions
medication
analgesics NSAID steroids - risk of osteoporosis Anti-coagulation diuretics/anti hypertensives anti-depressant resp meds
SocHx
social history
work
sports - biomechanics, aggravating activity
hobbies
FHx
family history
genetics
patients goals/expectations
Symptomatic
Functional
Social
subjective examination session
rate pain behaviour of symptoms quality of pain red flags history of present complaint past medical history medications social history family history patient goals/expectations
lumbar spine red flags
Cauda Equina syndrome – gait, saddle anaesthesia, B&B symptoms
cervical spine red flags
Vertebrobasilar insufficiency – 5 D’s; dizziness, diplopia, dysphagia, drop attacks, dysarthria
