SUBJECTIVE

EXAMINATION
SUBJECTIVE ASSESSMENT
 Information presented by the patient based
on his or her perception, understanding, and
interpretation of his or her clinical state.
 Subjective data is gathered from the patient
telling you something that you cannot use
your five senses to measure.
OBSERVATION
 Without saying a word, start picking
information from the patient from the very
first moment.
 Everything patient do is a potential clue to
his problem.
HISTORY OF THE PRESENT
CONDITION (MAIN PROBLEM)
 You begin your session with the following
question, or one like it. “What seems to be
the problem?”
 Elaborate on the chief complaint in detail.
 Avoid medical terminology and ask from the
patient in simple language that is familiar to
them.
 Ask OPQRSTA for each symptom.
 PAIN(OPQRST)
 Onset of disease
 Positon/Site
 Quality,nature,character
 Relationship to anything or other bodily function
 Radiating
 Relieving or aggravating factors
 Severity
 Timing
 Treatment
 Other examples of subjective data from a
patient's perspective include itching,
dizziness, nausea, vertigo etc.
 Subjective data can also obtained by asking
questions about sleep, lifestyle, age, marital
status,occupation,race,religion, social and
work environment.
 In this we could add VAS/NPRS
 If patient have more than one symptom like
chest pain , swollen legs and vomiting then
take details of each symptom individually.
BODY CHARTS
 The main problem is usually recorded on a
body chart.
 The standard anatomical chart of body shows
an anterior and posterior view of the body.
 It is the ideal place to reflect the
description of symptoms.
ANATOMICAL POSITION
BEHAVIOUR OF SYMPTOMS
 How long the symptoms have been present
 A Typical 24-hour pattern
 What aggravates it?
 What eases it?
 Any particular activities that bring on
symptoms.
 Slow or sudden onset
SPECIAL QUESTIONS

 General health

 Operations

 Weight loss

 Drugs (steroids, anticoagulants)

 Rheumatoid arthritis (RA)

 Osteoporosis
 Diabetes

 Spinal cord/Cauda equina symptoms

 Dizziness

 X-rays

 Working environment

 Constant or night pain