CHAPTER 1 Assessment

Introduction

Patients present with a range of signs and symptoms for which they are seeking relief and if possible a cure. However, before this can be achieved, it is essential to undertake a primary patient assessment. Ineffective and inappropriate treatment may result if the practitioner has not taken into account information obtained from the assessment. To avoid missing important information a flexible but systematic approach should be adopted for assessment. This chapter explores why it is necessary to undertake an assessment and considers specific aspects of the assessment process.

Why undertake a primary patient assessment?

Information from the assessment helps the practitioner to:

• arrive at a differential diagnosis or definitive diagnosis

• identify the likely cause of the problem (aetiology), e.g. trauma, pathogenic microorganism

• identify any factors that may influence the choice of treatment, e.g. poor blood supply, current drug regimen

• assess the extent of pathological changes so that a prognosis can be made

• establish a baseline in order to identify whether the condition is deteriorating or improving

• determine the need for further investigations (e.g. X-rays)

• assess whether a second opinion is necessary.

All the above information is essential if the practitioner is to provide effective treatment and care for the patient.

The assessment process

Assessment comprises three elements: the interview, observation and tests (Table 1.1). Information from the interview and observation is used to formulate ideas about the likely diagnosis and cause. Further information may be sought via the interview and the use of clinical and specialist tests or investigations. The practitioner uses the data gained from the assessment to formulate a hypothesis(es) from which a diagnosis will be reached. This diagnosis will be used to inform the management plan (Fig. 1.1). Where possible, the cause (aetiology) of the problem should be identified, as part of the management plan would be to eradicate or reduce the effects of the cause.

Table 1.1 Components of an assessment

Component
Assessment interview	Presenting problem Personal details Medical history Family history Social history Current health status
Observation and clinical examination	Vascular Neurological Musculoskeletal Dermatological Footwear
Laboratory and hospital tests	Urinalysis Microbiology Blood tests History Gait analysis X-rays Other imaging techniques Electrocardiography (ECG) Nerve conduction studies

Figure 1.1 The stages of assessment.

What has been outlined above is the ideal. In reality, patients often present with ill-defined problems and it is not possible to reach a definitive diagnosis. In these instances the practitioner explores a range of likely possibilities and develops the management plan in relation to these possibilities. This approach focuses on symptom reduction and palliation.

To make a good assessment, a practitioner requires good interviewing (communication) and observational skills. It is also essential that the practitioner has effective listening skills and knows when and which questions to ask the patient (see Ch. 2). Research has shown that most diagnoses are based on observation and information volunteered by the patient (Lee et al 2006, Sandler 1979). For patients with complex pathology, it may not be appropriate to follow normal models of diagnostic practice as many conditions will not present in a typical ‘textbook’ fashion. This has led to the development of subspecialty models of clinical assessment such as the ‘permeable brick wall’ theory for neuromuscular assessment developed by Maitland et al (2001). This theory recommends that the clinician should treat a patient’s presenting symptoms rather than follow a treatment programme based on an exact diagnosis, as this may not be possible because of the variable and mixed nature of neurological symptoms and conditions.

Clinical, laboratory and hospital-based tests provide additional data. Clinical tests include physical examination of the patient (e.g. assessing ranges of motion at joints, taking a pulse) as well as near-patient tests, e.g. assessing blood glucose levels with a glucometer. Most clinical tests are relatively quick and inexpensive to carry out and in most instances give fairly reliable and valid results. Technological advances mean that there is an increasing number of available clinical tests. Tests in laboratories and hospitals are more expensive and can be timeconsuming. Such tests should only be used when it is necessary to confirm a suspected diagnosis, in cases of differential diagnosis or when the outcome of the test will have a positive influence on treatment.

Risk assessment

Risk assessment serves two purposes:

• Identification of patients who need immediate attention

• Predicting which patients are ‘at risk’.

On account of the demands on time it is often necessary for the practitioner to differentiate between those patients who need immediate attention and those who do not. Table 1.2 summarises the presenting problems which should be given high priority. In clinics where there are lengthy waiting lists, patients may be screened initially to assess whether they have one or more of the problems listed in Table 1.2 and are then given immediate treatment.

Table 1.2 Presenting problems which should be given high priority

Problem	Features
Pain	Constant, weightbearing and non-weightbearing Affects patient’s usual daily activities
Infection	Raised temperature (pyrexia) Sign of acute inflammation Signs of spreading cellulitis Lymphangitis, lymphadenitis
Ulceration	Loss of skin May or may not be painful May expose underlying tissues
Acute swelling	Unrelieved pain Very noticeable swelling May have associated signs of inflammation
Abnormal skin changes	Distinct colour change Discharge may be malodorous Itching Bleeding