As promised in Trog Blog #9, subpoint #4: I am going to talk about the subjective examination process.
It’s honestly where most of the diagnosing happens. It’s where you listen to a patient and decide what the top possible diagnoses are. It’s also where you game-plan your objective examination to rule in/out those top diagnoses. And it is where you get a feel for the patient–how worried they are, preferred style of communication, apprehension, etc etc.
It’s actually, in my opinion, the most skilled part of the job. The interventions are easy and tend to take care of themselves, if you get the diagnosis correct. So, how do you do it?
There are a lot of different ways to visualize the process; this is just how my brain does it. I envision all of the possible diagnoses as floating boxes—kind of like how Beth Harmon, in Queen’s Gambit, plays chess on the ceiling…just that I do this without a bunch of drugs…
The first part is roughly knowing what all the boxes “sound like” during a subjective. Although this is a gross oversimplification, it lets me be more present during an evaluation. “My shoulder hurts” will be in a lot of boxes; “My arm is numb” is a different set of boxes; “my shoulder clicks” is a different set.
I usually start with the least amount of information to get rid of some floating boxes. Example: 30 year-old female with shoulder pain. That gets rid of a lot of boxes, but it keeps some in play. Pretty much all lower extremity boxes go away (duh!). I keep things like: Frozen shoulder, rotator cuff tear, labral tear, cervical spine referral, etc, on board.
Then I do a chart review, if available. This lets me know what systemic- or disease-processes may be contributing. She has nothing of note on her chart? Nothing changes. She is a Type II diabetic? My Frozen Shoulder box starts to sound more plausible.
Then I take a pause. I recognize that I am setting myself up for additional bias by prepping things ahead of time. I wipe my brain clean before I talk to a patient.
Then I listen. And I try to listen really well. I listen for clues that point me toward a box–things like “numbness” or “dropping things more recently” or “pain at night” or “pain right here” (points to AC joint or whatever).
I also listen for the quality of the patient’s communication. Do they sound irritated? Are they sad? Scared? Do they seem stand-off-ish? Are they really relaxed?
I typically try to talk as little as possible during this part. I make sure to stay engaged–I face them, I don’t have my laptop in front of me, I give them affirmatives (“mmhmms”, “uh-huhs”, “okays”, head nods). I ask clarifying questions only as needed. And then usually finish it with a summary–basically asking the patient if I got the story correct.
During all of that, my brain is playing the shell game. Moving boxes around. Pushing some out of the way. Pulling others in.
To get better at this, I also ask myself: what question could I ask that allows me to rule in/out one of these boxes confidently? If I am between cervical spine, frozen shoulder, and rotator cuff tear, one example might be: “do you have any numbness in your hands?”. If she says no, I’m more confident that her neck isn’t involved and it’s looking more like the other boxes. This doesn’t mean neck ISN’T possible, it is just less likely.
But my questioning may never help me get the difference between frozen shoulder and rotator cuff. Both can be stiff, painful at night, unfun to reach with, etc.
That’s when you get to use your objective tests! I know that a classic frozen shoulder should have active range of motion (AROM) losses that are very similar to passive range of motion losses (PROM). But a rotator cuff, for the most part, should have AROM loss > PROM loss. PROM should be intact.
The beautiful part? I got down to 1-3 diagnoses by 1) listening 2) asking a few good questions and 3) setting up my objective to make sure I rule them in/out.
This is what everyone means when they say “80% (or whatever percentage they feel like quoting) of the diagnosing is done during subjective examination”.
Hard to follow? Yeah, it was hard to write this one coherently. Instead, may I suggest you watch a video of me explaining this below?
Remember, ask good questions…don’t live in caves…
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