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The Examination Process Matthew R CHAPTER 2 © sbayram/E+/Getty Images The Examination Process Matthew R. Kutz, PhD, ATC, CSCS OVERVIEW LEARNING OBJECTIVES This chapter focuses on the injury evaluation pro- After completing this chapter, the reader will be able to cess and how a proper evaluation contributes to do the following: the clinical diagnosis and patient’s plan of care. 1. Describe the injury evaluation process. Many nuances to the injury evaluation process 2. Understand the necessity of a systematic and contribute to the identification and classification organized approach to injury evaluation. of an injury. These nuances also affect which body 3. Articulate key questions to ask when taking a parts are evaluated relative to the primary injury, history. the treatment options, and the overall plan of care. 4. Understand the importance and necessity of It is impossible to identify and discuss every pos- inspections, palpitations, and special tests. sible nuance during an evaluation in a text such 5. Understand the difference between the HIPS injury as this. Therefore, the skilled clinician is required assessment and the SOAP note-taking format. to integrate and assess a very complex “web” of 6. Understand the difference between primary and information supplied by the patient, the clinician’s secondary evaluations. observation of the injury (if he or she was there), the patient’s presentation, the clinician’s experienc e, valid and reliable research evidence, and the FUN FACTS ABOUT INJURY experience and input from reliable stakeholders (eg, other health care providers and observations EVALUATION from witnesses). Sometimes, the information • Although all injury evaluations should be structured gathered from all of these different sources may and organized, they do not necessarily have to follow be contradictory, and so it must be carefully and a prescribed sequence. thoroughly scrutinized. • Injury evaluations should be divided into primary In this chapter, a common framework for and secondary assessments. Primary assessments gathering relevant information about a patient’s deal with life-threatening conditions and secondary injury and associated signs and symptoms, history, assessments deal with non–life-threatening inspection/observation, palpation, and special tests conditions. (known as HIPS, or HOPS by other clinicians), will be introduced. These are the four elements mini- mally required to gather enough information to form a clinical diagnosis. The ways in which that Introduction information is documented and recorded in a SOAP One of the key domains within athletic training is for (subjective, objective, assessment, and plan) note the athletic trainer to be proficient at examination, will be discussed; these four sections are necessary to provide enough information in the medical record assessment, and diagnosis. The examination process to ensure ongoing and adequate patient care. 17 © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 18 Chapter 2 The Examination Process should be systematic and organized, and it should differential diagnosis requires that the clinician begin contribute to a valid clinical diagnosis and the patient’s to differentiate between two or more conditions that plan of care. However, the evaluation need not always share common signs or symptoms. Although signs follow a prescribed sequence. For example, there are and symptoms are sometimes used interchangeably, differences between a formal clinical evaluation (in a they have important differences: symptoms are gener- controlled environment) and an on-field evaluation ally subjective, whereas a sign is more objective. More (during competition or practice, usually in front of specifically, a sign is something that can be observed, spectators). In certain situations, the clinician may measured, and recorded by a health care professional, decide to abbreviate or reorder one aspect of the eval- and a symptom is something that the patient feels and uation to expedite the process or to accommodate a may or may not be able to explain or measure. For more emergent situation. There are also distinctions example, a patient with a fever may show a sign of a to be made between primary and secondary evalua- certain temperature, say 102°F, and the symptoms of tions. A primary evaluation assesses life-threatening headache and fatigue. Using the HIPS framework of conditions, whereas a secondary evaluation assesses injury evaluation, the clinician is better able to form non–life-threatening conditions. a differential diagnosis and determine between signs All injury evaluations, regardless of type, should and symptoms. Table 2.1 is a breakdown of the HIPS be structured and organized. The examination process framework used in a clinical examination. is generally structured according to history, inspec- An accurate history can be extremely revealing tion (or observation), palpations, and special tests. for the clinician and can help uncover many salient The acronym HIPS (or HOPS) is commonly used to issues. One of the most significant aspects that a good delineate this evaluation format. In the next sections, history contributes to is uncovering the mechanism the HIPS framework and each of these aspects will be of injury (MOI). Identifying the MOI often reveals the discussed. specific cause of or at least identifies the event that immediately preceded the injury as well as informs the clinician of any underlying medical conditions History that may contribute to or influence the current condi- Taking and recording a patient’s history is consid- tion and quality of life. Discovering the MOI is critical ered by many clinicians to be the most revealing por- to determining the forces that have been applied to tion of the evaluation process. An accurate history is the injured body structures. very important for determining a differential diag- The history-taking process requires active listen- nosis, which is a list of the possible diagnoses asso- ing, thorough note taking, and skills at framing open- ciated with a patient’s complaint. The process of a ended questions. Although a history usually occurs at Table 2.1 HIPS Framework Framework Elements Description Subjective Component History The clinician asks the patient about the onset and mechanism of the injury and associated signs and symptoms. Objective Components Inspection/Observation The clinician observes how the patient presents with the injury (gait, posture, etc) as well as any measurable factors, such as edema, ecchymosis, atrophy, range of motion, signs of infection, and other observable characteristics of the injury. Palpation The clinician begins to “feel and touch” the injured area to identify areas of point tenderness, swelling, pain, or discomfort and may also use it in conjunction with assessing range of motion in determining end feel. Special tests The clinician intentionally stresses the joint or injured body part to assess the integrity of the structures and soft tissue near and around the injury, which helps to determine extent and involvement of the injury. Other special tests include neurologic screening and muscle function tests (eg, break tests or manual muscle tests). © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. Inspection 19 the beginning of the evaluation, it is often necessary 3. When did the injury occur? to revisit it throughout the entire evaluation process. 4. What activities cause pain? A thorough history provides information about the 5. What activities reduce pain? activity that was being performed when the injury 6. Describe the type/sensation of pain (stabbing, occurred, the extent of the injury, the anatomic struc- aching, throbbing, radicular, radiating, etc). tures involved in the injury, and any limitations in 7. How did the injury occur/how did you do it? participation or desired activities that resulted from 8. If you landed awkwardly, how did you land? the injury. 9. What position was the joint in when you got hurt? Taking a history typically involves asking about 10. How long ago was the injury? past medical history as well as history of the current 11. Do you remember anything specific that hap- condition. Past medical history helps the clinician to pened immediately before or after the injury? establish any previous history that is relevant to the 12. Did you hear any noises (eg, click, pop, snap, or current condition (eg, any previous surgeries, previous crack) when the injury occurred? injuries, residual complaints, general health status, or It may also be beneficial to use a mnemonic to current medications). It is also important to identify help remember what questions should be asked. One any comorbidities. Comorbidity, or when a patient has one or more distinct conditions, is associated with such mnemonic that aids in the collection of a rele- worse health outcomes, more complex clinical man- vant history is OPQRST: agement, and increased cost of care.1 A thorough his- 1. O = Onset of the injury—What happened? tory includes asking questions about other medical 2. P = Provocation—What makes this problem feel conditions, including comorbidities. The history of the better or worse? current condition is to identify the cause of the cur- 3. Q = Quality of the pain—How would you describe rent complaint. It is necessary, at this point, to deter- the pain? mine current level of function, which is to determine 4. R = Region or radiation—Where is the pain? any restrictions to current activity and any limitations 5. S = Severity—How bad is the pain? the patient may be experiencing in any aspect of life. 6. T = Timing—How long has it been hurting? Did These limitations transcend sports participation and the symptoms change? include activities of daily living. A thorough history Asking questions such as these will help the cli- can also help determine any changes in activity that nician make an informed and accurate clinical diag- have occurred and, if activity is still possible, helps to nosis. The more specific the questions can be without identify if there any changes to activity patterns. badgering the patient, the more likely that meaningful and accurate information will be obtained.
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