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.

Body Chart

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
Intensity

Relationship of each symptom or area

Used to determine diagnosis and prioritising of treatment

Necessary in determining diagnosis and monitoring asterisk signs

Aggravating Factors

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

Easing Factors

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

Special Questions

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?”

Current History

Onset and mechanism of injury
Behaviour/progression of symptoms since onset
Treatment since onset

Past History

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

Social History

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

Goals

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

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.

Tips

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.

Alicia

References

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.