Physiotherapy Subjective exam
When you assess a new patient in physiotherapy you are trying to make a diagnosis but also to get to know and understand the patient, both physically, medically and psychologically.
The subjective examination allows you to do this and is the framework by which physiotherapists work in order to ensure they are both listening to the patients story and also gather the relevant information they need to make and informed clinical decision about what the next steps to take in the patients care.
In the video above I go through the subjective examination in detail giving specific examples of what to look out for and what questions are important to give you all the information you need.
History Of presenting condition (HPC)
The first thing that you need to establish is what brought the person in to see you in the first place, even if you know why this is its important to ask this first question as it allows the person to tell their story and will often give you a lot of the information you need without even needing to ask it.
The questions of importance in this section are:
- When did the pain start and was their an injury? (this will give you information on the length of time of the condition (Acute/Persistent) as well as whether there was trauma and start to give you an idea of what injury it could be)
- Have they had previous treatment or investigations? ( This gives an idea of what they have currently done to help themselves and what treatments you might want to include or NOT include!) It also gives you an idea as to whether investigations may be needed to rule out serious pathology eg fracture if there has been a trauma)
- Is the problem getting worse or better? (The progression of the condition will enable you to determine if you need to be keeping a close eye on the patient, if things are deteriorating then you may wish to refer on sooner if they continue to do so)
Presenting condition (PC)
Now we are going to be more specific about their actual site of symptoms and the behaviour of those symptoms.
- Where exactly is their pain? (location gives lots of clues in terms of the structures likely involved, plus if there is multiple areas of pain you could be dealing with a non-MSK condition or a centrally sensitised persistent pain condition.
- How does it feel? (The type of pain gives you more clues as to what the diagnosis might be, burning electric shock pain and tingling/numbness is more common in nerve related pathologies, sharp intermittent pain is more common with mechanical type pain)
- When is it there? ( constant pain gives and indication of more severe pathology than intermittent pain. it also gives you an index of suspicion of non-msk conditions especially if associated with night pain or a non mechanical pattern of pain)
- Referred pain patter? (If there is referred pain then it may give you an indication on the specific nerve root or structures that could be at fault)
- Aggravating and easing activities? (what brings the pain on and what eases the pain will give you an idea of how mechanical the pain is and what structures are being irritated when doing said activity that aggravates the issue)
24hr pattern/Night pain? (diurnal pattern gives an idea of any morning stiffness which could indicate rheumatology conditions or OA, night pain if unremitting would increase the index of suspicion of serious pathology of some kind)
These will be different based on the site of pain:
For the spine:
- Bladder/Bowell issues? (leaking, lack of control, lack of awareness of going for number 1 or 2, incontinence, overflow incontinence, inability to feel when empty or full)
- Saddle anaesthesia (lack of sensation when wiping themselves)
- Sexual Dysfunction (Altered sensation during intercourse, erectile dysfunction)
- Gait disturbance (Balance issues abnormal for them since the pain started)
Cauda equina syndrome needs to be ruled out in patients with back and leg pain. The condition requires an urgent referral to A/E if deemed to be a possibility so both knowing and understanding the use of the questions becomes important in these patients.
For the neck
5 D's and 3 N's
- Dysphasia (Swallowing issues)
- Diplopia (Blurred vision)
- Dysarthria (Speech issues)
- Drop attacks (Fainting)
- Nystagmus (Black spots in the eye)
- Neurological symptoms (Pins and needles numbness, weakness etc)
For the Periphery
- Locking of the joint
- Giving way
Past Medical History (PMH)
This is very important to rule out sinister pathology and also get an idea of how generally well the patient is and what other things they may be dealing with, which may guide your clinical reasoning process.
- Weight loss? (rapid weight loss without cause can indicate cancer)
- Unexplained fever/night sweats? ( prevelant in leukemia as well as in infection and lymphoma)
- Chronic fatigue (could indicate other systemic problems that the patient is not aware of)
Rheumatoid arthritis? (In family)
Steroid medication (long term can have influence on the joints and soft tissue health)
Previous history of cancer (large risk factor for developing cancer in the future or mets that can caused bone pain)
Previous operations or injuries on the same body part
Drug History (DH)
Getting an idea of the patients medication will also give you an indication of their general health as not all patient divulge a full medical history when you ask them about it.
The types of medication they are on will give you an idea of what they might be suffering with or managing from a health perspective.
It is important to find out what the patients social activities are as this is often the thing that the patient cares about the most!
- What job do they do? (postures and difficulty in working at present)
- Any sports/hobbies? (gives an idea of activity level and things they may want to get back to
- Family set up? (Lifting kids, care giving etc)
Impact on their social activities? (if pain is limiting the ability to socialise it can often have a large psychological effect)
This is by no means an exhaustive list and obviously the questions do not and should not be done in a robot type fashion as this will likely not lead to the generation of good rapport with the patient.
Getting a full history is complex and difficult and you will not always get it right (I know i don't)
Do the best job you can in trying to help your patients and try not to miss out the big things and gradually over time you will hone your skills and become better and better at assessing and recognising what is important.
Hopefully this helped you out, if it did then share it with someone who might also benefit and lastly thank you very much for reading.
I really do appreciate it!