Christine Short1 & Mary E. Lynch2 1 Associate Professor, Dalhousie University, Department of Medicine, Division of Physical Medicine and Rehabilitation; Department of Surgery, Division of Neurosurgery, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada 2 Department of Anesthesia, Pain Management and Perioperative Medicine, Department of Psychiatry, Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada Pain is what the patient says it is (Ronald Melzack, 1975) There is no objective imaging study or laboratory test that can measure pain; however, we can objectively measure the manifestations of pain. The patient’s verbal report and behavior provide most of the information. In some cases, there is a limp or some other obvious manifestation of the pain. However, there is no hint of the pain in many cases; it is invisible to the observer. Carr et al. [1] have reviewed the importance of narrative in pain and the fact that the patient’s description is particularly required in chronic pain because there are no specific diagnostic tests for pain; words are often all the patient has [2]. Thus, the best clinical tools in pain assessment, in cognitively intact adults, are the clinician’s capacity to listen to the patient as they tell their story, careful observation and a thorough physical examination that includes a thorough neurosensory and musculosketal examination. It is best to start with an open‐ended question, simply ask the patient to tell you about their pain. Make time for the patient to tell their story. Later you can fill in the gaps. Table 8.1 presents the key elements required in a full biopsychosocial history. In most cases, in order to obtain a full history and physical examination as well as communicating diagnosis and suggested management, the clinician will need 90–120 minutes. We realize that this length of time will not be possible in all clinical contexts, so it is reasonable to obtain this information over several appointments, depending on the clinical setting. The important thing is that the initial assessment is not complete until you have obtained all of this information. A thorough initial assessment is critical in building a good therapeutic alliance with the person experiencing pain. Without this, it will be difficult to build a successful management plan. Within the first few minutes, ask the patient about their expectations or goals. Patients may not be looking for complete relief and will often surprise you by saying they are looking for strategies to control or cope better with the pain. They may also present specific goals such as a wish to walk farther, play with their grandchildren or return to work, whether this be unpaid work within the home or wage‐earning work outside of the home. Table 8.1 Essential elements in the history and physical examination of the patient presenting with chronic pain. Given the importance of psychosocial determinants of pain and related disability, enquiry into these factors is imperative. Chapter 11 presents the details of this assessment. We provide brief observations here. When patients present with a chief complaint of chronic pain, they are usually comfortable reviewing the details of the pain. However, some patients may experience discomfort with questions along psychological lines fearing that you are suggesting that the pain is psychologically caused. Starting with a focus on the physiological aspects of the pain will ease some of these fears. A statement like, “Now that I have heard about the pain, I would like to get to know more about how this pain is affecting you and what strategies you are using to get through each day with it.” This places the questions about mood and anxiety in context for the patient. You can then move into questions regarding the impact the pain has had on sleep, appetite, energy, concentration, mood and sex drive. If the patient reports depression or significant irritability of mood, this is the time to ask about suicidal ideation. You may begin to explore this by asking, “Has it ever gotten to the point where you feel that life might not be worth living? If yes,“Have you ever come close to acting on these thoughts?”, “Can you tell me about it?”, “What stopped you?”, and “How do you feel now?” The Columbia Suicide Severity Rating Scale (C‐SSRS) is an excellent tool for assessing suicidal ideation and risk [3]. It is a questionnaire used for suicide assessment that was developed by multiple institutions, led by investigators at Columbia University with National Institute of Mental Health support. It is now available in over 140 country‐specific languages and has been used in multiple settings including schools, universities military, first responders, primary care and in research trials. The full risk assessment version is 3 pages long with the initial page assessing several risk categories and protective factors. It measures severity and intensity of suicidal ideation, behaviors and lethality of suicide attempts. It also comes in a short 6 question “screener” version that allows an initial rapid assessment of imminent risk (see table 8.2). A positive response to any of the items on the screener indicates the need for further assessment and care, a positive response to items 4,5 or 6 indicates the need for immediate referral to professional care. Table 8.2 Columbia Suicide Severity Rating Scale (C‐SSRS) Screener. Used with permission from The Columbia Lighthouse Project.
Chapter 8
Clinical assessment in adult patients
Introduction
The history
Patient expectations and goals
History
Chief complaint and history of present illness
Exploring location, onset, quality, context, severity, duration, modifying factors, spontaneous/ evoked aspects and associated signs and symptoms (sleep, appetite, energy, concentration, memory, mood, libido, suicidal ideation), previous treatment for pain (include complimentary therapies), previous consultations and investigations
Functional history
Impact of pain on level of function
Mobility: bed mobility, transfers, wheelchair mobility, ambulation, driving and community access and devices required
Activities of daily living: e.g. bathing, toileting, dressing, eating, hygiene and grooming
Instrumental activities of daily living: e.g. meal preparation, laundry, telephone use, home maintenance, child or pet care
Communication issues, sexual function
Past medical and surgical history
Specific conditions: cardiopulmonary, musculoskeletal, neurological and rheumatological and Medications
Psychosocial history
Past psychiatric and addiction history
Home environment and living circumstances, family and friends support system, vocational activities, finances, recreational activities, spirituality and litigation
Family history
Review of systems
Physical
General medical physical examination
Cardiac
Pulmonary
Gastrointestinal
Genital/urinary and pelvic (if applicable)
Lymphatics
General neurological and mental status examination
General appearance, behavior, flow of speech, ability to participate in the history and physical exam process
Orientation: most patients in an outpatient setting will be oriented to person, place and time; in an inpatient setting, questions regarding re‐orientation may be more important
Affect: is affect congruent with the content of the interview?
Attention and concentration
Thought content: is it consistent with questions posed and the context of the pain interview or is there evidence of disorganized thought, delusional thinking? Is there any unusual behavior that might suggest a perceptual abnormality such as hallucinations?
Cranial nerve
1 Odor perception (smell)
2 Confrontation visual fields, fundi, visual acuity
3,4,6 External ocular movements, diplopia, nystagmus, pupil response
5 Jaw strength, corneal reflexes, facial sensation
7 Facial power
8 Auditory acuity (hearing)
9 &10 Dysarthria, dysphagia
11 Sternocleidomastoid and trapezius power
12 Tongue atrophy strength and fasiculations
Sensation
Light touch and pinprick
Presence or absence of allodynia, hyperalgesia, cold and heat hypersensitivity
Motor
Key muscles (Biceps C5–6, brachioradialis C6, triceps C7, finger flexors C8, finger abductors T1, Hip flexors L2, knee extensors L3–4, ankle dorsiflexors L4‐5, ankle plantar flexors L5‐S1)
Strength (0 = no movement, 1 = flicker, 2 = movement with gravity eliminated, 3 = movement only against gravity, 4 = movement can be overcome by resistance, 5 = full power)
Coordination
Involuntary movements
Tone/spasticity
Reflexes (roots)
Biceps C5–6, brachioradialis C6, triceps C7, knee extensors L3–4, ankle, ankle plantar flexors L5‐S1
Musculoskeletal
Inspection
Behavior ease of movement during the history and physical examination, symmetry edema, color change, atrophy, joint deformity, quality of skin, hair distribution
Palpation
Joint stability
Range of motion (active and passive)
Strength testing
Bony/joint/muscles and soft tissues
Include assessment of trigger points of myofascial pain
Psychological history
Past Month
If YES to 2, answer questions 3, 4, 5 and 6
If NO to 2, go directly to question 6
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