The subjective examination is often undervalued in the assessment and management of a patient. It is the most crucial aspect of the examination as it determines the severity, irritability and nature (SIN) of the patient’s condition. Good questioning leads to the formation of primary and secondary hypotheses, possible methods of treatment and likely prognosis of the injury.
Recently, I assessed an active 30 year old female with left ankle pain. Her body chart suggested a tibialis posterior tendinopathy, with a previous left evertor tendinopathy and left gastrocnemius tear. On questioning about medications, the patient stated she was taking Ampyra, a common medication used to improve walking speed in those with multiple sclerosis. This completely altered the rest of my questioning and physical assessment. This simple question, often forgotten or undervalued, drastically changed my diagnosis and prognosis in this case.
The following structure allows quick transition between sections of the subjective examination. By following this routine, you should have a solid understanding of the patient’s condition and reduce the risk of missing a sinister pathology.
Area of symptoms – must determine each aspect of symptoms for each area
- Location and distribution
- Symptoms – pain, pins & needles, numbness
- Type of pain – ache, burning, throbbing etc
- Constant or intermittent
Relationship of each symptom or area
- Used to determine diagnosis and prioritising of treatment
Necessary in determining diagnosis and monitoring asterisk signs
Essential in determining irritability (a concept described by Geoff Maitland, the degree to which an injury is exacerbated by certain activities)
Aggravating activity – time to onset, intensity of symptoms, time to ease on ceasing activity
Useful in treatment selection
24 Hour Behaviour
Valuable in determining an inflammatory condition
- AM – intensity of symptoms, time to ease
- Day – behaviour during day e.g. depends on activity, worse by end of day, better as day goes on
- PM – painful/comfortable positions, time to get to sleep, wake in night, time to return to sleep
- Night sweats
- Malaise – feeling of general discomfort, uneasiness, being “out of sorts”
- 5D’s (Cx) – dizziness, dysarthria (speech), dysphagia (swallow), diplopia (vision), drop attacks, assists in determining risk of vertebral artery involvement
- Cord signs – glove and stocking paraesthesia, balance problems
- Cauda equina signs – bowel or bladder changes (urinary retention, unable to control anal sphincter)
- Medications – for pain relief, for other conditions
- General Health – “do you have any other medical conditions?” “how is your general health?”
- Investigations – “have you had or been referred for any scans?”
- Onset and mechanism of injury
- Behaviour/progression of symptoms since onset
- Treatment since onset
- Previous occurrences – when, mechanism, previous treatment & response, recovery time
- Previous injuries related to presenting condition – e.g. 3/12 post ankle injury, presenting with anterior knee pain
Assists in return to work and return to sport rehabilitation, determines goals of treatment
- Employment – nature of work, hours per week, effect of injury on work status
- Living situation – dependents, home duties, stairs, activities of daily living
- Recreation – level of activity, sessions per week, guides rehabilitation
Often forgotten, it’s crucial to know the patient’s expectations. You may be overestimating or underestimating their desired level of activity. It also helps with understanding the patient’s perspective on their injury and giving insight into some cognitive factors.
Questionnaires can be used to provide valuable information. With a growing awareness about chronic pain and biopsychosocial models of pain, these can provide invaluable information often missed in a standard assessment.
- The Opening Question...it must be short, direct, and encourage the patient to tell you their issue and be the same with every patient. Some examples are “Tell me about your problem” “So, what’s the problem?” “How can I help you?” “What can I do for you?”
- Complete your body chart, including clearing other areas, before continuing. It allows a comprehensive view of the injury, preventing you getting a nasty surprise of arm numbness during your “current history” questioning.
- Follow up on answers with further questioning if there’s confusion...”you wake in the night, is it pain that wakes you?” “you’re experiencing blurred vision, do you usually wear glasses or have vision problems?”
- When asking about morning pain, ask “how is your pain/symptoms in the morning compared to before you went to sleep?”, this narrows the interview to the pattern of their current pain rather than their 10 year history of aching knees.
- General health...often people say “I’m fine” or “good” when asked about general health. In the Australian culture we have a tendency to downplay any illnesses. I find it best to ask “do you have any medical conditions...so no diabetes, heart conditions, lung conditions, osteoporosis etc”.
- “We’ll come back to that”...the perfect way to direct the interview where you want it to go, if a patient starts discussing their past 20 years of medical history when you still haven’t determined their body chart, this line is a lifesaver.
Maitland, G. D. (1991). Peripheral manipulation (3rd ed.). London ; Boston: Butterworth-Heinemann.
O'Sullivan, P. (2012). It's time for change with the management of non-specific chronic low back pain. British journal of sports medicine, 46(4), 224-227.
Refshauge, K., & Gass, E. (Eds.). (2004). Musculoskeletal Physiotherapy: Clinical Science and Evidence-Based Practice. Sydney: Butterworth Heinemann.