Performing a thorough, but concise subjective history is essential prior to performing your physical examination. Each question that is asked should guide you to a follow-up question. These answers should then correlate with the physical exam measures you choose to perform. For example, if a patient states she fell on her left buttock and her symptoms are aggravated by forward bending, you absolutely need to check her cardinal plane flexion and sacral mobility. Always correlate a specific aggravating factor to a measureable functional movement.
A good format to follow:
1) Have the patient describe what their problem is in their own words. Is the patient having pain, numbness and tingling, weakness? Don't assume every patient has pain. Listen to how their describe their symptoms.
2) When did their symptoms start? Asking when the symptoms began allows you to determine if the symptoms are traumatic or insidious in nature. Additionally, this question can help you determine what structure may be involved. For example, a traumatic knee injury may guide you toward ligament insufficiency versus knee pain of insidious onset may lead you to think patellofemoral pain.
3) How has the pain changed since onset? Has the pain changed in quality, progressed, or gotten better? Do the symptoms have a specific pattern throughout a 24 hour period?
4) Can the patient describe aggravating and alleviating factors? Make sure there are alleviating positions or activities.
5) What is the nature of the pain? Is is constant or intermittent, sharp or dull, stabbing, throbbing, and/or aching?
6) Any significant past medical history? If a patient comes into clinic with L shoulder pain, but also has a history of cardiovascular disease, you need to ask some follow up questions. Always inquire about PMH!
7) Has the patient every injured this region before? This includes past surgical history to the area.
8) Is the patient having pain anywhere else in the body? In PT school, one learns to check the joint above and below. I challenge you to check all joints that may be associated with the area of dysfunction! Often times a patient will forget to tell you about a calf pain when they are having low back pain OR a wrist pain when they are having shoulder symptoms. Sometimes you need to assess more than 1 joint away from the primary pain.
Remember: A good clinician should obtain 85-90% of their information from the subjective history and initial interview.
What other questions do you ask during the initial interview?
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7/24/2015 12:44:04 am
Jim, thanks for the post! Why are we taught to ask about the specific nature of the pain? Based on what the patient answers (constant or intermittent, sharp or dull, stabbing, throbbing, and/or aching), how does that change what you are thinking (in terms of structures involved), and how does this influence which tests and measures you prioritize in your objective exam?
7/30/2015 04:02:06 pm
Thanks for the comment Spencer. Great question. The nature of pain is very important. If the patient states the pain is intermittent this means pain is NOT constant. Constant pain is a red flag for PT so I try to make sure they have times of pain relief prior to treating them. If a patient states a pain is shooting, I will often inquire about numbness and tingling after. Often shooting pains can indicate neural involvement. Based on the location of symptoms I will perform some sort of neural tensioning afterward. For example, shooting pain from the low back to calf, I would perform a SLUMP or SLR.
1/3/2022 03:18:04 am
I really like your article and the info such blessing info.
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