CHAPTER 16 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.
CautionHistory 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.
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.
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.
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
Be aware of the management regimes implemented by other professionals in the team as they may have implication for the assessment, treatment choice and overall management.
For example, a patient being fed using percutaneous endoscopic gastrostomy (PEG) may fatigue quickly and therefore the assessment may need to be carried out over 2–3 short sessions. As receiving proper nutrition is a high priority for this patient, the assessment should try and fit around the feeding timetable. Other considerations include the patient’s bladder and bowel management and communication strategies. This information should be easily accessible within the hospital setting but must also be pursued outside of this area. In the community setting, other non-healthcare agencies may be involved and their input must also be considered.
Previous therapy
Patients with longer-term conditions may have previously received therapy. Find out what was involved and the outcome. Their previous experience may colour the patient’s expectations of the present time. Ask if they were given home exercises? Did they do them? Did it help? This may give an indication of their level of motivation. What is the patient’s expectation of physiotherapy? This gives a clue about the patient’s insight into their condition and if they are realistic about the future.
Pain
Investigation of pain symptoms is important for the therapist, however it may be more convenient and less distracting for the patient to postpone this questioning until the objective assessment (S3.29).
Past medical history (PMH)
At this stage, the therapist needs to investigate any other medical conditions and co-morbidities which may influence the patient’s clinical presentation and which will need to be taken into account during assessment, treatment, goal setting and predicting the functional prognosis for the patient:
Co-morbidities
For example, mental health problems, learning disabilities, asthma, diabetes mellitus, osteoarthritis, postural hypotension and cardiac arrhythmias.
Drug history (DH)
Knowledge of the medication taken at the present time by the patient is important in terms of any relevant contraindications to therapy treatment and any related side-effects which may influence the assessment and treatment. For example, some drugs include side effects such as nausea (dantrolene), drowsiness or postural hypotension (tizanidine).
The long-term drug management of some symptoms may also result in secondary problems for the patient. For example, antispasmodic medications that work systemically (baclofen and tizanidine) to reduce hypertonic muscle activity are not discriminatory and therefore also affect other non-hypertonic muscles. The long-term use of these medications to reduce general muscle activity can cause underlying muscle weakness and loss of function separate to the primary condition (Dones et al. 2006).
It is also important to establish how the patient administers their medication. Can they manage themselves or do they need help? Is this assistance physical or a problem with memory/understanding? Does the administration require special/nursing skill? This latter questioning may be more relevant outside the hospital setting, but it is certainly worth considering prior to discharge from hospital.
Social history (SH)
In order to plan the objective assessment, treatment, maintain a patient’s motivation and set appropriate realistic goals, the therapist needs a picture of what the patient was able to do before this incident compared with what they can do at present. The style of questioning will be dictated by many factors, including:
The setting
For inpatients, some of this information can be sourced from other members of the MDT or the medical notes. In outpatients/community settings the majority of this information may need to come directly from the patient.
The level of function of the patient
It would be inappropriate to ask a patient who arrived at the department by bus whether he can walk to the bathroom by himself. However, if he reports the upper limb as his main problem then a detailed discussion related to how he washes, dresses and feeds himself is justified. It would also be inappropriate to blindly continue through the range of questions regarding mobility with a patient who is clearly severely disabled or at a very acute stage. Therefore it is necessary to be sensitive and adaptable with questioning and set the level and amount of data collected appropriately.
The following will give the therapist some idea of the type of information required:
Activities of daily living (ADL)
A detailed understanding of the patient’s involvement and abilities related to personal ADL and domestic ADL will give an idea of their general level of activity and motivation. It may also highlight any issues with active/passive range of movement (ROM), strength, fine finger function, and balance which will allow the objective assessment to be more focused. Of course the ability of the patient to carry out this type of function will largely be dictated by whether their dominant hand is affected by the present condition or not.
Personal ADL (PADL)
The therapist needs to investigate both previous and present level of ability for:
Washing
Enquire do they wash in the bathroom or at the bedside?
If they go to the bathroom do they wash at the sink or in the shower? Is the shower over the bath or can they walk in? Are there rails to assist getting into the shower? If they use the shower do they stand for the entire time or do they have a shower seat?
Do they have and can they use a bath?
When washing, how much do they do themselves? Include areas where hygiene is important such as underarms, feet and hands. Include shaving for men.
The majority of people would prefer to wash themselves; if this is not the case the therapist needs to investigate why.
Is the patient physically unable to wash? Have they taken on a sick role? Are carers taking over needlessly to save time and not allowing the patient to be independent?
This depth of questioning may appear excessive, however to ask ‘Do they wash independently?’ may lead to an answer of ‘yes’ even though what actually happens is that their carer brings a bowl of water to the bedside and they wash while sitting on the bed. This is not truly independent.
Dressing
This area needs to be investigated in the same detail.
Enquire whether they can pick out their clothes from the cupboard? If not, is it because they are not physically able or do they have a perceptual/visual problem.
Does their carer lay out their clothes?
Can they do buttons or do they wear pullovers and elasticated waists to avoid the problem? Can they do up shoe laces? Can women manage a bra and men manage a tie?
Feeding/drinking
In situations where no speech and language therapy (SALT) assessment has been carried out, ask about the ability to eat and drink. Most importantly:
Do they have difficulty swallowing? Do they cough or choke after eating or drinking? If a problem is identified in this area, that is not currently being managed, then it is the therapist’s responsibility to make a referral to SALT so that the patient can be properly assessed. In this case, a physiotherapy respiratory assessment will also be indicated.
Investigation related to the act of eating/drinking is also necessary. Can they use a knife and fork? Can they cut up their own food? Can they transfer food from plate to mouth successfully?
Toileting
Information regarding continence of bladder and bowel should already be available in a hospital setting. However, if a problem is identified that is not being managed, questioning should be discrete and sensitive followed by a referral to the relevant professional. It is always worth checking where incontinence is highlighted, whether the patient has accidents because they simply cannot get to the toilet quick enough. A brief enquiry related to the ability to remove the relevant clothes for toileting and carry out their own hygiene post-toileting may also be informative.
Domestic ADL (DADL)
Questioning related to the present level of ability in these activities will not be relevant in a hospital setting. However, an understanding of the patient’s previous levels, to which they may strive, is appropriate. Where required investigate both previous and present levels for:
Cooking
Did they do the cooking before this incident?
What can they manage now and how do they do it? For example, can they pick up a full kettle or saucepan? Can they make themselves a sandwich? Can they prepare a proper meal or do they use microwave meals?
Cleaning
Did they do the cleaning before this incident?
What can they manage now and how do they do it? For example, can they do the hoovering? Can they manage light dusting? Can they make the bed or iron clothes?
Shopping
Did they do the shopping before this incident? Can they manage shopping at the local shop? Can they manage at a supermarket? The latter two situations have very different physical demands. If they do not go out shopping, is it related to a physical constraint or is it because they do not want to be seen in public?
Mobility
Note that the patient’s mobility may change at different times of the day. This could relate to factors such as general fatigue, other non-related conditions, poor motivation or medications but when identified, should be investigated thoroughly. Enquire about these different aspects of mobility prior to the present condition and at present:
General mobility
This will include examples of all transfers, such as sitting to standing, sitting to lying, rolling, etc. When possible, ask the patient about these transfers in functionally relevant circumstances. For example, can they manage to get from lying to sitting over the edge of the bed in the morning? Can they stand up from the toilet/low sofa/armchair? These situations have different demands.
Walking indoors
How far can they walk indoors?
Are they independent? Do they use a walking aid? Do they hold onto the furniture? This is extremely unsafe. Do they need assistance from a relative or carer? If yes, how much assistance? Is help required to stand up or while walking?
Walking outdoors
How far can they walk outdoors?
Are they independent? Do they need a walking aid and/or assistance? How do they cope with slopes (up and down), rough ground, kerb stones, other pedestrians?
Stairs and steps
Are they independent? Do they use the hand rails? Do they use a walking aid and/or need assistance.
Falls
The National Institute for Clinical Excellence (NICE) guidelines for falls (2004) recommend that older people be asked routinely whether they have fallen in the past year and the frequency, context and characteristics of the fall(s). When the individual reports recurrent falls within the year, the NICE guidance is that they should be offered a multifactorial falls risk assessment (S3.34).
Other
Do they do any form of exercise at home? What type? How often? Do they feel it benefits them and if so how? How do they cope walking in unfamiliar surroundings? Do they drive, ride a bicycle or use public transport?
Clinical hints and tips
An easy way to gain the majority of this social history (as long as conversation is guided) is to ask the patient to talk through a normal day. This also provides insight into the patient’s general activity levels, motivation and how much responsibility the patient takes for themselves.
Environment
A detailed investigation around this topic is important in all areas but especially so in an outpatient and community setting and as part of discharge planning in the hospital setting. Although in some settings a home visit will be carried out prior to discharge, it is still useful to gain an overview of the patient’s environment to enable the therapist to give a personal focus to goals and treatment.
Do they live in a house, bungalow, flat, caravan?
Is access to the home manageable? Are there any steps outside? Is there a handrail on the steps/stairs? Which side is it on?
Ask about the general layout of their home? Is there a bathroom downstairs?
Is the area they live in urban/rural, hilly or flat? If relevant, make similar enquiries related to work and any separate venues used to pursue hobbies?
If problems related to the housing environment are identified and are not being managed, then the therapist is responsible for a referral to the appropriate agency (Occupational Therapy, Social Services, etc.).
Psychosocial
Psychosocial factors play an important part in the physical, cognitive and emotional wellbeing of the patient. However, sensitive questioning may be required and where issues arise that are outside the therapist’s area of competency, a referral to the appropriate professional is essential. The therapist should consider the following:
Personal factors
These maybe reported more frequently by close friends and relatives. For example, lack of confidence, low self-esteem, depression, anxiety, stress, challenging behaviour and lack of motivation. A sudden change in the role of the patient in relation to the family can cause great upheaval and stress for all and can have serious financial implications.
Life style
Support
Planning the objective assessment
The role of the therapist is to interpret the information that the patient relates to them in order to plan the objective assessment and implement patient-centred goals and effective treatment. This requires clinical analysis of the subjective assessment in terms of:
Following this analysis, the therapist should be confident to start making decisions to ensure that the objective assessment is more focused. This skill takes time to develop but becomes easier with experience.