The other week I had a new, fairly young patient who came in with lower back pain and a very long medical history with various organ difficulties. On subjective assessment she stated that she couldn't lie on her back due to her high pain and that all the pains that she experienced (her neck, shoulders, whole back and down her leg) were the same severity 4/10 (0-10 pain scale) and like her pins and needles, down her opposite leg to the pain, were constantly there. She had been like this for FOUR years and hadn't seen anyone about it. All her aggravating factors increased her pain to 4/10 which I dutifully wrote down (realising later this was the same has her resting pain) and they yet again were all considered one pain.
After talking to my supervisor about the subjective results I realised that just taking it as she said it and filling in the form was not good enough. I had to start asking specific questions and try repeating them with different wording to get a result, which added up more than 4/10 at rest And with aggravating activities. Also to diagnose a patients problems I would have to find which of her pains were increased with the various activities and compare them to the resting pains. Aggravating factors are not just there as precautions during assessment or as a measureable tool for treatment effectiveness but they also help to diagnose the issue if you have the activity, the place of pain and the pain level.
I went back to the patient and worded my questions better, breaking down each pain and starting with 'if this pain is 4/10 now what does it increase to with this activity'. By doing this I was able to separate the pains and when they happened, find out what things aggravated each part and by how much. I have now used this principle in the subjective of every new patient, it not only saves coming going back in and asking more questions but helps you with essential objective assessments, possible diagnosis and gets you thinking about treatment. Although you still have to carry out your objective using all the assessments (as you should with new patients), the specific ones you highlight from subjective results will more often than not show the results you predicted.
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I have definetly learnt the need for very specific subjective questioning, in an inpatient hospital setting. Patients I have seen are often frequently re-admitted, and I have learnt that they become very good at telling you what they know will allow them to be discharged home- such as slightly altered stories of how they are coping at home etc. I found a helpful way to get around this is not only through specific subjective questioning, but also by liasing with other team members about what the patient has told them. Using 'standard' questions/ forms can often not give you a very in depth perspective on the patient.
I agree. That's one major thing that i learnt on my musculo placement is being able to change the way you question clients to get an answer that will help with your diagnosis. It sounds easy to do, but certain patients struggle with describing their symptoms. Changing the way you ask the question in a way they will understand makes such a huge differnece and makes it a lot easier to diagnose!
I agree that careful wording is key to getting a good understanding of a patients history of presenting complaint and aggravating/easing factors. However I sometimes think that this is easy to talk about and hard to do. Something that frequently frustrated me when doing my musculoskeletal clinic was when my supervisor looked at my notes, decided they didn't contain enough depth and then asked the patient the exact same question that I did only to receive a different reply. Grrrr. By the end of the placement I had found that summarising what the patient told me back to them and putting a couple of bits of information together was often helpful for clarifying what they were telling me. Also good to develop rapport by proving that you are listening to them. Probably important to watch that you are not putting words in their mouth though.
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