PS 1001:03 Lecture Notes - Lecture 9: Visual Analogue Scale, Physical Therapy, Hypoesthesia
Be able to state the components of a subjective assessment and how
to gain information.
Can vary between clinics and patient groups
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Standardised format often used
Sections
Biographical
Surname, first name - ensure to check spelling and pronunciation
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Address
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Occupation - sedentary of active, does treatment effect their work
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Phone no.
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Sex
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Age
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Date of birth
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If they don't answer phone when trying to get details, make sure to call back
to protect confidentiality
History of present
condition (HPC)
Cause/factors e.g. sporting injury
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Mechanism of injury - what happened
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Onset - when it happened
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Duration - how long, has it gotten better/worse
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Investigations - A and E, GP, X-ray, any reports which can be used
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Any interventions - results to use
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Behaviour of problem since onset - better/worse/same
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Use body chart to mark areas
Body chart
Pins and needles (all the time? When? Type of pain?)
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Numbness
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Pain sites
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VAS visual analogue scale
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Screen clipping taken: 19/03/2018 10:56 AM
Severity
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L1 - subjective examination
Monday, 19 March 2018
10:42 AM
Week 5 Page 1
Document Summary
Be able to state the components of a subjective assessment and how to gain information. Surname, first name - ensure to check spelling and pronunciation. Occupation - sedentary of active, does treatment effect their work. If they don"t answer phone when trying to get details, make sure to call back to protect confidentiality. Duration - how long, has it gotten better/worse. Investigations - a and e, gp, x-ray, any reports which can be used. Numerical scale of 0 to 10 (0 = no pain, 10 = bad as it could be) Agg: how long before it gets worse, what makes it worse, vas. How long does it get worse/take to ease. What does the pain score get up to. I = irritability e. g. immediate (agg), 4hrs later (ease) ie. I = irritability e. g. immediate (agg), 4hrs later (ease) ie. time taken high/med/low. Position, disturbances = lack of rest, morning when they wake up, pillows.
