Subjective markers

One of the more common assessment recording methods used is the problem-oriented medical records
method, which uses "SOAP" notes. SOAP stands for the four parts of the assessment: Subjective,
Objective,Assessment, and Plan. This method is especially useful in helping the examiner to solve a
problem.

The aims of subjective assessment are to gather all relevant information about the site, nature,
behaviour and onset of symptoms, and past treatments. Review the patient’s general health, any past
investigations, medication and social history.

A complete medical and injury history should be taken and written to ensure reliability. This requires
effective and efficient communication on the part of the examiner and the ability to develop a good
rapport with the patient and, in some cases, family members and other members of the health care
teamThis should lead to a formulation of the next step of physical tests.

Always remember if you don't do a good job with your subjective assessment it is difficult to find the
right patient diagnosis

if you get to end of subjective assessment and you do not have a firm primary hypothesis of what might
happening then something has gone wrong Or you get to end of assesmet and unsure what patient
proplems are

If you are unsure what patient problem are you will be unsure where to start with your treatment and
rehabilitation

Subjective markers help to have good subjective assessment which is the most important part because
everything you do is reliant on it

Subjective markers are points that direct objective assessment,key points from subjective assessment ,
Helps To guide the objective assessment for better intervention plan

Subjective markers in complex cases or patient with more than one issue you should be able to identify
a probable cause of the patient problems then you can use your objective assessment to prove or
disprove failure to identify the problem cause you to do too many test in your objective assessment
irritating your patient

In Patient history the examiner should listen for any potential red flag signs and symptoms that would
indicate the problem is not a musculoskeletal one or a more serious problem that should be referred to
the appropriate health care professional. Yellow flag signs and symptoms are also important for the
examiner to note as they denote problems that may be more severe or may involve more than one area
requiring a more extensive examination, or they may relate to cautions and contraindications to
treatment that the examiner might have to consider, or they may indicate overlying psychosocial issues
that may affect treatment.It offers the patient an opportunity to describe the problem and the
limitations caused by the problem as he or she perceives them.
Red Flag Findings in Patient History That Indicate Need for Referral to Physician

Cancer :indicated by

Persistent pain at night,Constant pain anywhere in the body

Unexplained weight loss (e.g., 4.5 to 6.8 kg [10 to 15 lbs] in 2 weeks or less),Loss of appetite

Unusual lumps or growthsUnwarranted fatigue

Cardiovascular :

Shortness of breath,Dizziness,Pain or a feeling of heaviness in the chest

Pulsating pain anywhere in the body,Constant and severe pain in lower leg (calf) or arm

Discolored or painful feet Swelling (no history of injury)

Gastrointestinal/Genitourinary:

Frequent or severe abdominal pain,Frequent heartburn or indigestion

Frequent nausea or vomiting,Change in or problems with bowel and/or bladder function (e.g., urinary
tract infection)

Unusual menstrual irregularities

Miscellaneous :Fever or night sweats

Recent severe emotional disturbances

Swelling or redness in any joint with no history of injury ,Pregnancy

Neurological :

Changes in hearing,Frequent or severe headaches with no history of injury

Problems with swallowing or changes in speech

Changes in vision (e.g., blurriness or loss of sight)

Problems with balance, coordination, or fallingFaint spells (drop attacks)Sudden weakness

Yellow Flag Findings in Patient History That Indicate a More Extensive Examination May Be Required

• Abnormal signs and symptoms (unusual patterns of complaint)• Bilateral symptoms• Symptoms
peripheralizing

• Neurological symptoms (nerve root or peripheral nerve)• Multiple nerve root involvement
• Abnormal sensation patterns (do not follow dermatome or peripheral nerve patterns)

• Saddle anesthesia• Upper motor neuron symptoms (spinal cord) signs• Fainting• Drop attacks

• Vertigo • Autonomic nervous system symptoms • Progressive weakness

• Progressive gait disturbances• Multiple inflamed joints• Psychosocial stresses

• Circulatory or skin changes

In addition , psychological stressors are sometimes considered to be yellow flags that alter both the
assessment and subsequent treatment. Divorce, marital problems, financial problems, or job stress or
insecurity can contribute to increasing the pain or symptoms because of psychological stress. What
support systems and resources are available? Are there any cultural issues one should be aware of?
Does the patient have an easily accessible living environment? Each of these issues may increase stress
to the patient. Pain is often accentuated in patients with anxiety, depression, or hysteria, or patients
may exaggerate their symptoms (symptom magnification) in the absence of objective signs, which may
be called psychogenic pain, psychosocial aspects can play a significant role with injury.These processes
have been divided into different colored “flags”but it is important to note that these psychological flags,
other than the red flag, are different from pathological “flags”In these cases, it may be beneficial to
determine the level of psychological stress or to refer the patient to another appropriate health care
professional.When symptoms (such as, pain) appear to be exaggerated, the examiner must also consider
the possibility that the patient is malingering. Malingering implies trying to obtain a particular gain by
conscious effort to deceive. Summery of psychology process

Cognitions : How we think about our pain may influence it

Interpretations and beliefs may increase pain and disability

• Catastrophizing (irrational thoughts that something is far worse than it is) may increase pain

• Negative thoughts and beliefs may increase pain and disability

• Expectations may influence pain and disability

• Cognitive sets may reduce flexibility in dealing with pain and disability

Attention :Pain demands our attention

• Vigilance may increase pain intensity

• Distraction may decrease its pain intensity

Emotions and emotion regulation: Pain often generates negative feelings; these negative feelings may
influence the pain as well as fuel cognitions, attention, and overt behaviors

• Fear may increase avoidance behavior and disability

• Depression may increase pain disability

• Distress, in general, fuels negative cognitions and pain disability

• Positive emotions might decrease pain

Overt behavior : What we do to cope with our pain influences our perception of pain

• Avoidance behavior may increase disability

• Unlimited activity (overactivity) may provoke pain

Reaction to stress

Aches and pains• Anxiety• Changed appetite• Chronic fatigue• Difficulty concentrating•Muscletension
(headaches)• Sweaty hands • Difficulty sleeping• Irritability an impatient

Sign vs. symptom

Sign is a physical response linked medical fact or characteristic that is detected by a physician,
Physiotherapist, nurse, or medical device during the examination of a patient.

They can often be measured, and this measurement can be central to diagnosing a medical problem.
Example :High blood pressure

 Sometimes, a patient may not notice a sign, and it may not seem relevant. However, in thehands of a
medical professional that knows how this sign relates to the rest of the body; the same sign can be the
key to treating an underlying medical problem.
 Symptoms refer to the feelings and concerns that you feel. they can be perceived only by the person
who is experiencing them

Symptoms: eg pain , numbness ,weakness,time pattern

Sign :tenderness,axial loading,simulated rotation

EXAMINATION OF VITAL SIGNS

Temperature, Pulse rate, Breath rate, Blood pressure, SpO2,6th additional vital sign" pain"

 Cardinal signs/Vital signs provide quantitative measures of the status of the

cardiovascular/ pulmonary system and function of internal organs.

 Variations in vital signs are a clear indicator of change in the patient’s physiological

status.

Tips for subjective assessment

1,know your question and (predict answer)before walk in the room

even if you don't know the problem but 95%of your subjective assessment could ,and should be
same ,it give you confidence about question

It help to avoid muumbing through and sounding unconfident and It help you to understand questions
rather than just asking one question at a time and receive an answer to each question before
proceeding with another question. Having structured subjective assesment ensure :you are ready for
any patient walking to your clinic

2,speaking at a level and using terms the patient will understand and listen; and being empathic,
interested, caring, and professional it is important that the examiner politely but firmly keeps the
patient focused and discourages irrelevant information. Questions and answers should provide practical
information about the problem, to obtain optimum results in the assessment, it is important for the
examiner to establish a good rapport with the patient ,take a time to ensure you get right information
before you progress

3, Repetition helps the examiner to become familiar with the characteristic history of the patient’s
complaints,and if answer doesn't sound right ask again there may be misunderstanding and
misinterpreation

Reference.. devid magee book

https://newgradphysio.com/3-tips-to-a-better-subjective-assessment/