Subjective examination – Analysis

Please read the case study SE and form as many hypotheses as you can with each
piece of information as you read (under each of the sections of the SE). You need to
start forming hypotheses from the first section of the SE, i.e. social history - age, as
clinical reasoning is an evolving concept that we do as we assess

What hypotheses can you form about:

-age: Recently widowed, post-menopausal, OP, normal degenerative

changes, unlikely to be disc (dehydrate with age)

-occupation: standing for long periods- back in extension,

Biopsychosocial issues?
Less personal working environment

-hobbies: walks dog- keeps fit,

Poor footwear?
Attends lots of clubs- good social outlets.

- activity/exercise levels: walks 2 miles every day,

Activities and games included in pensioners club.
Good level of exercise.

- Information on body chart: symptom distribution, nature / description of

pain/symptoms etc: intermittent ache- somatic pain eg.? Mechanical, ?
RA, ?OA, ?spinal stenosis, ?scoliosis
No pins and needles, no neuro compression
Surrounding joints clear

- factors: PA- working at sink- pelvis drops into anterior tilt

Standing and walking- facet joint in close packed position (could be
cause of pain??)
PB- If PA aggravated – indicates referred pain from PA

- factors: ?Facet joint (gets relief in flexion- opens joint up)

Mechanical?- eases with movement

- 24 hr pain pattern: Difficulty bending getting dressed-

- Eases with hot shower- ?OA or ?RA/ inflammatory
- Eases within an hour of getting up- ?RA
- Wakens during night (could be due to lying in same position all night-
stiffness?)

Updated September 2019 (D Liddle) 1

- Mandatory questions: High blood pressure-? Stress, Hysterectomy-
high chance of OP

- X-ray - ? normal degenerative changes

- HPC: chance of developing chronicity (lasting longer than 6 months),

worried about pain and management- biopsychosocial factor, ?fear, ?
negative impact on prognosis

- PMH: Chronic? - ? mental health at times of bed rest

- Patients perceptions and expectations: previous positive experience

with physio therefore aids good prognosis

- GP not encouraging- may be cause for concern. Yellow flag? Pt

beliefs and attitudes may be negative. Could contribute to poor
prognosis.

- Worried condition will worsen, its lasting longer. Yellow flag?

- Has a goal (to walk dog), will help motivation and aid good prognosis

Which of your hypotheses is most positive – i.e. what is your working

diagnosis that you need to negate or prove in the OE? what is the
main driver of pain?
- Arthritis of a Facet joint?

Then complete the planning the OE worksheet (see below)

PLANNING THE OBJECTIVE EXAMINATION

1. What is the irritability of the patient’s condition?

Low to moderate irritability
Can walk a mile before pain comes on and eases in 10 mins

2. How much can you assess on day one?

Low irritability- can carry out majority of assessments

3. Does any aspect of the S/E indicate caution?

Worried about increasing pain
GP made negative comments

Updated September 2019 (D Liddle) 2

 Lives alone- lack of family support
Previous back pain and lasting longer than 6 months- risk of
chronicity

4. What aspects of the S/E may indicate there are neurological

changes?
No evidence of neurological involvement

5. What psychosocial involvement is there?

Lives alone- recently widowed
Retired
Exercises individually
Other than clubs low social interaction

6. What areas must you examine?

Lumbar spine, Thoracic spine, cervical spine, hip, SI joint, check
for dermatomal patterns

7. Do you expect an objective comparable sign to be easy or hard to

find? Explain.
Hard to find – Non specific lower back pain

8. On palpation what relationship do you think you might find

between pain and resistance?
Don’t understand question?

9. What aspects of the S/E indicate likely objective findings?

Stiffness and degenerative changes reported on x-rays.
Objective findings may be negatively affected my timing of
appointment eg. Very stiff in am

10.What are the main drivers of this patient’s pain/disability?

Bio- Degenerative changes
Pyscho- Fear of condition worsening, worried about managing,
fear of increasing pain
Social factors eg. Lives alone, no children, limited family support-
recently widowed.

Start back screening tool

- Total score 4/9
- Subscore 3
Medium risk

Updated September 2019 (D Liddle) 3

BY
Emily Burrows, Mary McDermott, Niamh Breslin, Hannah O’Neill,
Rachael Hand

Updated September 2019 (D Liddle) 4