Note: While the subjective assessment is examined in detail in this chapter, the objective assessment will be dealt with separately in each following chapter, as they will all be slightly different depending on the type of condition being assessed. Therefore, each chapter after this one will actually be an objective assessment of that type of condition i.e. the chapter on Respiratory assessments is actually a description of the objective assessment performed on a respiratory patient.
Without saying a word, you could start picking information from the patient from the very first moment. This begins as soon as you see the patient in the waiting area and continues until they leave your company. Everything they do is a potential clue to their problem. Take note of how they’re sitting (or are they standing?). Do they look like they’re in pain? When they stand up, is it a struggle, or effortless? Watch them walk to the cubicle, do they limp, do they favour one side, are they steady on their feet? If they have to undress, watch them closely. If they’re saying they can’t lift up their arm and yet remove a T-shirt with no apparent discomfort, are they faking it (if it’s a medico-legal issue) or are they just having a pain-free day?
History of the Present Condition (Main problem)
You might begin your session (after taking details) with the following question, or one like it. “What seems to be the problem?” While this could elicit many responses, people will usually tell you what it is in terms of a functional deficit i.e. they’ll tell you what they can’t do, or name an activity that causes pain. You can’t expect a patient to reply, "Well Bob, I seem to have torn my left rotator cuff in what I think was a hyperextension injury." It’ll more than likely be something along the lines of, "It hurts when I sit for a long time", or "I can’t walk as far as I used to", or "My neck hurts when I type". You may occasionally get a response like: "My cow pushed me up against the wall", as I did when I treated a farmer with rib fractures. My first thought was that this guy had a very different approach to looking after his animals than more conventional farmers.
It’s part of your ability as a clinician to interpret these answers. As you gain experience you’ll start doing it subconsciously, but in the beginning it may take some effort. You’ll need to break the activities down into the likely actions/postures involved (are they sitting, standing, bending over, rotating, extending, jumping, running, etc.), analyse the functional muscle groups (what’s contracting, what’s relaxing?), think about the structures under duress (ligaments and tendons being strained) and figure out the potential causes (traumatic injury, arthritis, ‘wear and tear’, poor posture, fracture, etc.).
The main problem is usually recorded on a body chart, all which have similar features and all are similarly asexual. The chart on the right is a more or less standard view of one. It shows an anterior and posterior view of the body (some charts have left and right views as well) and shows it in the anatomical position. It is the ideal place to reflect the description and relationship of symptoms. You could qualify them as following: nature, depth, frequency and impact. If the symptom is pain, you could add the VAS/NRPS grade. Some departments will have their own symbols for describing pain, stiffness, acute, chronic, whether it radiates, etc.
Behaviour of symptoms
A Typical 24-hour pattern; What aggravates it; What eases it; Any particular activities that bring on symptoms
Past Medical History (PMH)
It’s important to have a good understanding of the patient’s history at this point. You need to know whether this kind of thing happens often. Is it long-standing (chronic) or is it a recent thing?
Social/Family History (SH/FH)
FAMILY HISTORY: to rule out whether the pathological condition is due to hereditary transmission,example:diabetes also it can out the relationship with others
Past surgical history (PSH)
Have they had recent surgery that might give a clue to an underlying problem? If a patient has had a spinal fusion 6 months ago, and is now complaining of back pain, might the two be related?
- General health
- Weight loss
- Drugs (steroids, anticoagulants)
- Rheumatoid arthritis (RA)
- Spinal cord/Cauda equina symptoms
- Working environment
- Constant or night pain
What is the effect of the problem on their activities of daily living (Basic DLA, DLA and Participation): - Personal care - Home management - Social life and hobbies - Work