A good subjective examination at your patient's initial examination will guide your physical assessment, diagnosis, treatment plan and ultimately the results you achieve with your patient. One of my patients is a builder with an insidious onset of anterior shoulder pain, and early in the history I started to suspect his biceps tendon (or surrounding tenosynovium or fatpads) could be the source of his pain. He had a lot of pain in the morning, when he hammered, pushed wheelbarrows and lifted heavy pieces of wood above his head, the usual sort of things. With some delving around during the history, we identified an activity that he performed regularly through the day that seemed to be a major factor in this pain continuing, and may make all the difference in his recovery. This got me reflecting on the importance of a patient's story, and I wanted to share a few key tips on subjective assessment.
Subjective history
- Arguably the majority of the important information gathered in your treatment session is obtained in the subjective assessment. Have the courage to spend a lot of time on subjective history. You will pick up an enormous amount of potentially valuable information that you would otherwise miss with superficial history taking.
- Listen to your patient for clues on how to treat their pain, and activities to modify. Patients will reveal a lot of valuable information on aggravating factors, movements and positions you can modify to help your patient improve.
- Keep red flags in the back of your mind when taking history and assessing e.g. night pain, unusual symptoms, cauda equina, unexpected weight loss, neurological symptoms in multiple dermatomes.
- Follow up ‘red flag’ symptoms. It is not enough to ask a question and ignore a positive or equivocal response. Clarify the details of the symptoms if you get a positive response, and refer for further investigations.
- Don't immediately blame your treatment if your patient is not getting better, ask questions to find out more e.g. if they have been out dancing all weekend and their heel pain is aggravated. (On the flip side, we do love to take the credit when patients improve, but remember to find out if your patient has modified their activity when they improve as well!)
Download "5 Bonus tips for a great subjective assessment
Coming back to our builder, one of his main aggravating movements was shoulder extension, and when I spent time going through his day to identify activities that may place him into shoulder extension, (which he couldn't initially recall), we eventually identified the trusty hammer. When he pulled the hammer out of his toolbelt or replaced it on the lateral aspect of his hip, his shoulder moved into a fair amount of extension, causing sharp pain, and he repeated this movement hundreds of times each day. Alongside isometric biceps tendon loading in a non-provocative position to settle the tendon, one of the activity modifications we implemented was to move his hammer on his toolbelt into a more anterior position. The goal here was to limit shoulder extension for a while, allowing his long head of biceps tendon/anterior shoulder to settle down. So far it is working a charm.
If we listen for the little clues provided by your patient in the subjective assessment, they can help you identify and minimise aggravating activities in the short term, and improve the success of the treatment for your patient, which is really what this game is all about.