Subjective assessment

Published on 03/03/2015 by admin

Filed under Neurology

Last modified 03/03/2015

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Subjective assessment

Clinical hints and tips

Prior to starting the subjective assessment consider your verbal and non-verbal communication. The environment, your body language and your position in relation to the patient will influence the interaction.

Personal information

• Weight – to be used as part of a Manual Handling Risk Assessment.

Caution

Before you approach the patient, always double check that you have the correct patient. Patients with a neurological impairment may not always be completely reliable!

Present complaint (PC)

• The diagnosis

• The patient’s main problem at the present time

• The patient’s perceptions of their strengths and weaknesses

• The patient’s goals and expectations of physiotherapy.

History of present complaint (HPC)

Clinical hints and tips

Some of this information may have been collected by other professionals. To avoid asking the patient the same questions again, look at other available notes. If the multidisciplinary team uses electronic records, these should be readily available.

The therapist’s questioning for this section will need to be targeted differently depending upon the type of condition (progressive or non-progressive) and the stage of the disease (acute or chronic). The important history to establish, is that leading up to the present complaint including:

Date of onset of the signs/symptoms

This section outlines detail related to the patient’s initial symptoms for the present compliant in terms of their presentation, onset time (gradual or sudden) and circumstances.

Example 1 – 1/4/09 Mr X had a left cerebrovascular accident [or CVA], while at home. Initial symptoms were slurred speech and right upper limb weakness which came on gradually. There was no loss of consciousness. Admitted to hospital via the A&E department.

Example 2 – Mr X presented with an exacerbation of lower limb spasticity, associated with MS 3/07/09. Pt referred to outpatient clinic by GP.

Progression of the condition

The therapist should note any changes involving the initial symptoms up to the present time. In a chronic or progressive condition this may involve a long period of time. If this is the case an outline of the main history is sufficient. The history of the symptoms tells the therapist about the behaviour of the condition in the past and may therefore assist in goal setting and prediction of prognosis.

Example – Mr X was diagnosed with MS 22/11/07. Since this time he has had one exacerbation of his lower limb weakness per year, with no new additional symptoms over this period. On each occasion, a hospital admission was necessary and with medical treatment and physiotherapy he recovered sufficient mobility to return home.

Analysis – With no new neurological symptoms this may indicate that Mr X’s present condition is the result of inflammation/exacerbation of existing plaques rather than the formation of a new lesion.

Investigations and results

This section should include the results of any investigations carried out which are relevant to the present condition. In a hospital setting scan results are usually found in the back of the medical notes or electronically in computerized systems. In non-hospital-based settings, the patient’s GP should be able to provide these facts. Make a note of any results and the date they were undertaken (find the most recent results). This will help the therapist to start predicting the signs and symptoms likely to present and therefore plan a focused objective assessment.

Example – MRI scan showed a small infarct in the right parietal lobe 03/04/09.

Medical management

Note how the patient’s condition has been managed by the medical team, such as neurosurgery or other medical interventions. This is relevant in all conditions and at all stages of disease and may impose limitations on the therapist’s assessment and treatment.

Medical observations

In an acute condition or exacerbation of a chronic condition, the therapist should check the patient is medically stable before approaching to carry out the subjective assessment. Of course in a hospital-based setting with an acute admission, the therapist may continue to assess and treat patients for emergency care.

Other management

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Neurological Assessment A Clinicians Guide