Subjective information Flashcards
What data is used for clinical decision-making in diagnosis?
History, physical findings, functional status, and where appropriate, imaging.
What is included in the logical approach to subjective history?
Present complaint (PC), history of presenting complaint (HPC), past medical history (PMH), drug history (DH), social history (SH).
What should the opening section of a present complaint assessment focus on?
Allowing the patient to talk without interruption, determining MOI (mechanism of injury), and locating symptoms.
What are the SIN factors in subjective assessment?
Severity (M/M/S), Irritability (level of activity to irritate), and Nature (patient’s description of pain).
What are common symptoms of vertebrobasilar insufficiency (VBI)?
5 Ds (dizziness, diplopia, dysarthria, dysphagia, drop attacks), 3 Ns (nystagmus, nausea, numbness), coordination/balance changes.
What are absolute contraindications in assessment?
Cancer of the nervous system or vertebral column, acute inflammatory infection, recent/worsening neurological signs, cauda equina lesions, spinal cord injury.
What factors should be considered in social history?
Occupation, hobbies, exercise/sport, family life, and lifestyle factors (smoking, alcohol, diet).
What are common symptoms of L2 nerve root compression?
Pain, tingling, numbness, muscle weakness, radiating pain down the back of the thigh, paresthesia.
What are common MOIs for L2 nerve root compression?
Bone spurs, trauma, herniation.
What is the vertebrobasilar arterial system, and why is it significant?
A system supplying blood to the brainstem, occipital lobes, and cerebellum, vulnerable to atherosclerosis and plaque buildup.
