Subjective Examination

Question 1

Name all 5 steps to follow during a Subjective Examination.

Answer 1

• Step 1: What brings the client to see you.
• Step 2: Body Chart.
• Step 3: Nature of the Pain.
• Step 4: Behaviour of Symptoms.
• Step 5: Special Questions.

Question 2

Explain what is involved in Step 1: Main Injury Complaint.

Answer 2

• Why the client is seeking help.
• What their main issues are.
• How it impacts their day to day life.

Question 3

Explain what is involved in Step 2: Body Chart.

Answer 3

• “Show me where it hurts”.
• “Does it extend above / below here?”
• Consider Referral of pain.
• Central Lesion can result in larger area of referred pain. (E.g. Facet Joints can refer as far as the foot).

Question 4

Explain what is involved in Step 3: Nature of Pain.

Answer 4

• Description of the pain as this can offer details on the Structures Involved.
• Intensity / Severity.
• Abnormal Sensations.
• Constant / Intermittent.

Question 5

Explain what is involved in Step 4: Behaviour of Symptoms.

Answer 5

• Aggravating and Easing Factors.
• Effects of Sitting / Standing.
• Relaxed Prolonged Standing.

Question 6

Explain what is involved in Step 5: Special Questions.

Answer 6

• Weight Loss.
• Cough / Sneeze.
• Medications.

Question 7

What structure may be damaged if the client has a Sharp, Buring pain?

Answer 7

Nerve.

Question 8

What structure may be damaged if the client has a Deep, Boring, Poorly Localised pain?

Answer 8

Bone

Question 9

What structure may be damaged if the client has a Superficial, Localised, but referred to other areas pain?

Answer 9

Joint

Question 10

What structure may be damaged if the client has a Diffuse, Aching, Poorly Localised, often Reffered pain?

Answer 10

Vascular

Question 11

What structure may be damaged if the client has a Deep, Dull, Aching, Poorly Localised, Occasionally Referred pain?

Answer 11

Muscle

Question 12

Explain Step 2: Body Chart.

Answer 12

• “Show me where it hurts”.
• “Does it extend above / below here?”
• Consider Referral of pain.
• Central Lesion can result in larger area of referred pain. (E.g. Facet Joints can refer as far as the foot).

Question 13

Explain Step 3: Nature of Pain (Depth of Pain).

Answer 13

Depth can Offer information on structure involved.

• Muscles produce deep pain.
• joints are more superficial
• Highly innervated structures can give superficial feeling.
• Deep pain over large areas indicative of referred pain (particularly if pain is vague).

Question 14

Explain Step 3: Nature of Pain (Abnormal Sensations).

Answer 14

• “Any pins and needles, altered sensation experienced.
• Parathesia indicative with Neurological Condition.
• P+N, tingling indicative of ischaemia or peripheral nerves (can occur when nerves are compressed).

Question 15

Explain Step 3: Nature of Pain (Constant / Intermittent).

Answer 15

• Mechanical pain can be either!
• If Mechanical pain is constant it may vary with movement and position - but never completely vanishes.
• if Intermittent - Certain positions / movements will worsen or abolish sensations.
• Remember constant pain is just that - CONSTANT, no diurnal variations.

Question 16

Explain Step 4: Behaviour of Symptoms (Aggravating and Easing Factors).

Answer 16

• “What movements / Positions +,- symptoms?”
• Conduct Suitable tests based on feedback.
• Effects of Sitting / Standing.

Question 17

Explain the Effects of Sitting / Standing has on the injury.

Answer 17

• Sitting increases low back / intradiscal pressure.
• Sitting causes lumbar spine to become fully flexed and stretches posterior structures.
• Relaxed prolonged standing can place lumbar spine into end range extension placing anterior structures on stretch.

Question 18

Explain the effects of Diurnal Variations.

Answer 18

• Does pain + when lying down or is it due to daily activity?
• Pain from lying down may be postural (if prevents sleep consider acute inflammation or serious pathology).
• Pain from daily activity may ease within an hour and allow sleep.

Question 19

Explain the effects of Diurnal Variations continued…

Answer 19

• Morning stiffness = Inflammatory condition / inflammatory state.
• Joint stiffness accompanied by pain lasting more than 30 mins in the morning is regarded as acute inflammatory component.
• minimal or no pain with stiffness = degenerative conditions e.g. Osteoarthritis.
• Pain at end of day = indicative of mechanical stress causing inflammation.

Question 20

Explain Special Questions (Weight loss).

Answer 20

Rapid / Unexplained = indicative of malignancy.

Question 21

Explain Special Questions (Cough / Sneeze).

Answer 21

Increase abdominal and spinal canal pressure.

- Pain may be pathology common in lumbar and thoracic spines (spinal joints / rib articulations).

Question 22

Explain Special Questions (Medication).

Answer 22

Steroids - osteoporosis (inhaler, salbuterol).
Anticoagulants - poor tissue healing (warfarin).
Pain Killers - may mask severity of condition.
Diabetes - poor tissue healing, neuropathy.

Question 23

What are the 5 colour Flags?

Answer 23

• Red
• Orange
• Yellow
• Blue
• Black

Question 24

What does a Red flag insist:

Answer 24

Signs of serious pathology:

• Cauda Equina Syndrome
• Fracture
• Tumour
• Sudden weight loss
• Previous history of Cancer
• Saddle anaesthesia

Question 25

What does a Orange Flag insist:

Answer 25

Psychiatric Symptoms: - Clinical Depression - Personality Disorder

Question 26

What does a Yellow Flag insist:

Answer 26

- Beliefs and judgment of pain - Emotional Response (worry, fears, anxiety) - Pain behaviour and coping strategies (avoidance of activities due to expectation of pain)

Question 27

What does a Blue Flag insist:

Answer 27

Perceptions about the relationship of work and health: - Worried work might further injury - Unsupportive workplace

Question 28

What does a Black Flag insist:

Answer 28

System or Contextual obstacles: - Legislation for return to work - Conflict with insurance over injury claim - Any potential self gain.