Subjective Examination Flashcards
History of Present Illness
- Date of injury/diagnosis
- Family history of the condition
History of injury
- MOI
–>action taken after injury (e.g. continue to play sports/ stop & use ice)
- Any surgery?
- Any hospitalisation?
- Disease progression
- Presence of dyspnea
–>If presence, when does it occur and rating out of 10
- Effect of condition/injury on daily function (e.g. ADLs)
–>Independent vs dependent
- Mobility/ambulation status (any gait aid)
- Current exercise capacity (type, distance, duration, frequency)
- Equipment/home adaptations
–>E.g. brace/splints, wheelchair, gait aids, hospital bed, commode, railings/grab bars, bath bench
Pain Presentation (OLDCARSPP)
Onset- What happened to cause the pain?
Location- Where is the pain located?
Duration- How long has the pain been present far?
Character- Can you describe the pain? (e.g. sharp, dull, aching)
Aggravating factors- What makes the pain worse?
Relieving factors- What makes the pain better?
Severity- How would you rate the pain from 0 to 10 if 0 is no pain and 10 is extreme pain)?
Past pain- Have you ever had this pain or similar pain before?
Progression- Is the pain getting better, worse or staying the same?
Dizziness/vertigo
Fall/near fall (If yes–>fall Qs-DOFI)
-Description of fall
–>Environmental factors: lighting, rugs, debris in room/house, poor footwear
–>Personal factos: dizziness, altered vision, leg weakness, fatigue, balance change
- Onset of falls (when did that start)
- Freqency of falls
- Injuries/hospitalizations
–>loss of consciousness, facture
Recent investigation
Current/past treatment
- What are you currently doing to manage your condition/injury?
Why asking HPI is important?
Information related to the history of present illness is important since it allows me to understand the pateint’s current concerns in order to determine what I will assesss in my OE
Past Medical History
- I would ask if they have a history of
- Myocardial infarction, cardiovascular disease, hypertension, diabetes, blood clotting disorder
- and any acute/chronic respiratory condition
- I would also ask if they’ve had any major trauma/surgery, or if they’ve had this injury before
- I would want to know which medications they are currently taking.
- I would want to understand what their overall health looks like - do they smoke, drink alcohol, or have high stress?
Why is PMH import?
- Information related to past medical history is important as it can determine if there are additional co-morbidities that could impact physiotherapy
E.g.
Pt attending PT for Rx of mobility-related issues due to Parkinson’s
Their PMH includes HT and severe bil. knee OA
The activities included in Rx would need to be modified to accomodate the Pt’s bil knee OA and it would also be important to monitor the Pt’s blood pressure to ensure safe participation in PT.
Social History
Home Support
- Live alone or with someone (e.g. spouse, home care support)
- Driving ability
Living arrangement (house type, stairs)
- Ability to manage the stairs (if applicable)
Occupation
- Effect of condition/injury on ability to work/go to schoole
Hobbies, sporting activity
-Effect of condition/injury on ability to participate
-Return to sports requirement
Sleep quality/fatigue level
Why social history is important?
Information related to social history allows me to understand how my patient is managing their injury/condition in the context of their social life and what types of supports they have in place. This information can also be helpful with discharge planning
Cancer questions
For no known MOI/concerning signs/symptoms
- Have you had any recent unexplained weight loss?
- Do you experience night pain?
- Do you experience night sweat?
- Do you feel generally unwell?
- Is your pain unrelenting? (does not change with movement/rest)
Lx Mandatory Questions
Known MOI and injury to Lx spine
- Do you have any numbness/pain in both legs?
- Do you ever lose bowel or bladder control
- Do you have any numbness over area that would touch a bicycle seat?
Cx Mandatory Questions
Known MOI and injury to head/Cx/upper Tx spine
Dizziness- Are you experiencing any dizziness?
Disphagia- Do you have trouble swallowing
Disarthria- Do you have any difficulty speaking
Diplopia- Do you have any double vision
Drop attack- Have you experienced an episode where you collapse to the ground for no reason without a loss of consciousness
Perioral numbness- Do you have any numbness in the area around your mouth?
Nausea- Have you been feeling nauseated?
Nystagmus- Have you experience any vision-related changes/issue?
Why screening red flag is important
It is important to screen the Pt for a condition that is not appropriate for PT treatment and needs a referral to a different healthcare provider.
Goals
- What is the Pt looking to get out of PT?
- What would the Pt like to achieve short term vs long term?
- What would they like to get back to (work, sport, hobbies, activities of daily living)?
Why knowing the Pt’s goals is important?
Goals are important to discuss during subjective assessment
because treatment should be based on what the Pt wants to achieve. Determining the Pt’s goals for treatment will allow me to create a program that is patient-centered
Addition SE Questions for Pediatric Condition
If the case show
- working with a child 5 yo or younger
- If the child has any delays in physical/cognitive Fx (e.g. Autism, ADHD, DMD, CP)
Gross motor developmental history
- Do you have any concerns about your child’s gross motor development?
–>If so, please describle
- Has your child ever lost a skill that they previously had? (e.g. could sit independent and then lost the ability later)
–>If yes, what was that skill? - Current gross motor milestones
- Early gross motor milestones
–>How old was your child when he/she was able to do the following (ask appropriate one based on child’s current age) - Maintain independent head control
- Roll: prone to supine/supine to prone
- Sit independently
- Transition out of sitting
- Crawling+ description of crawling
- Pull to stand
- Stand with support
- Cruising (walk holding furniture)
- Stand independently
- Walk independently
- Run/jump/skip
- Kick/bounce/throw/catch a ball
