During the history, the doctor will ask you about your symptoms, when they started, how severe they are, how often you have them, what makes them worse or better, the type of pain (sharp, dull, ache, etc.) they produce, and where they radiate too (if they do). The frequency and duration of the symptoms is also important. The doctor will ask you to rate the severity of your symptoms. Detail is important to establish a baseline for your symptoms.
Outcome measures will also be used to determine how much your neck pain, low back pain, and headaches interfere with your functional abilities. Specialized outcome measures may also be used for your other symptoms (shoulder, knee, etc.). Your Activities of Daily Living (ADLs) will also be evaluated. This tells the doctor how much your problem interferes with your day-to-day life. Any disability of limitations that you have at work will also recorded.
Any preexisting problems or conditions will also be noted in the records. These conditions may be complicating factors in you current injury and must be noted as such. Complicating factors can slow your recovery or result in a less than optimal outcome. Apportionment, or how many of your current symptoms or the severity of your current complaints, is from these previous problems must be calculated by the doctor. This should be noted in the records as a baseline. Once you are back to this level, the injuries from this accident have been resolved and you can be released from this accident.
The doctor may order x-rays, if you don’t already have them. A review of any films you do have will also be done. After the review, the doctor may order additional studies, if warranted.
The examination is to help match the mechanism of your injury from the accident to the symptoms you experience. The physical examination findings from the various orthopedic and neurological tests should support the mechanism of the proposed injury. If the mechanism of injury and the examination findings do not match then there could be a problem.
Anytime there is a mismatch between the history and examination, it is up to the doctor to resolve it. The doctor must be able to explain why the history and examination do not concur. It could be due to an old injury, an inaccurate history of the mechanism of injury, or from functional overlay. The doctor should determine which it is and correct it or note it in the file. Any unanswered conflicts can result in problems later, if the case goes to peer-review or to court.
Once the history, outcome measures, any imaging studies, and examination have been completed, the doctor arrives at a working diagnosis. This should encompass ALL of the patient’s complaints (which should have all been examined). With the working diagnosis, the doctor can formulate a treatment plan to address all of the various injuries/problems. The goals of the treatment should be noted in the records as well.
Then the fun starts…the treatment!