A thorough initial exam includes questioning,
testing, and educating the patient
It’s the patient’s first visit. Mrs
Jones’ neck and right arm have been hurting for a few months, so she
found you through your yellow pages ad. She has never been to a
chiropractor, but the muscle relaxers aren’t working and her
next-door neighbor suggested she try a DC. Perhaps she has read some of the
negative billboards that seem to be popping up, or perhaps a friend had a
negative experience to relate. Whatever the reason, Mrs Jones is nervous.
She is worried that you will “crack her neck.” She’s not
really sure what you have waiting for her in the back office.
However, her experiences thus far with your office
have been positive. The first time Mrs Jones called the office, your
front-desk CA obtained all of the necessary information and gave her
precise directions to the office. Your insurance CA has checked her
coverage and is ready to explain the payment and benefits.
When Mrs Jones steps into your office, she is greeted
immediately and handed your detailed case history. Your staff offers
assistance with the forms in case she has any questions or does not
understand something. After she completes her forms, she is escorted to the
consultation office. This allows you the opportunity to review the
forms before you meet her and to prepare any necessary follow-up questions.
Fill In the Gaps
Your consultation office is well-planned, with diplomas and certifications artfully displayed. This
sets the stage, providing a professional basis for the examination that will follow. As you
enter the office, you extend your hand for a confident handshake. As you
and Mrs Jones begin to chat, you start to fill in the gaps that lie behind
the answers on the case history. Although she marked that she does not take
any medication other than muscle relaxers, she forgot to mention that she
is taking birth-control pills. However, many women take them nowadays, so
it doesn’t really count, does it? Also, although she doesn’t
consider herself a smoker, she smokes occasionally when she goes out with
her girlfriends on the weekends.
Mrs Jones says that she is not really sure how her neck
pain started. It seemed to happen gradually and has gotten worse, extending
into her right shoulder and arm over time. Although she did have a
fender-bender 2 months ago, it was “minor” and she is sure that
didn’t cause this problem. When you ask Mrs Jones if she has done
anything for the pain, she casually mentions that she may take her
husband’s prescription painkiller if the pain gets “too
bad.” She indicates that she mentioned the pain to her general
practitioner, who suggested muscle relaxers, but says they don’t seem
to be helping.
Sometimes, it seems as if patients forget the little
things they do that really seem to add up. Or, it seems as if they are
afraid to put these answers down on paper. Whatever the reason,
it’s your job to discover this information. It will assist you in
building your examination and making key clinical decisions.
Patient Education As you conclude the consultation, you take Mrs Jones
into the examination room, and ask her to gown before you examine her. (Yes, we can still gown in this day and age.) You meet her in
the exam room. As you begin the examination, you explain to her that you
will test some basics, such as height, weight, blood pressure, and heart
rate, as they give you a window into her general health status. Then you
will look at factors such as range of motion, palpation, orthopedic, and
neurologic tests to give you a complete picture of the root of her problem.
Due to the fact that she is on birth control and smokes occasionally, you
will perform George’s Test to rule out any stroke risks. When Mrs
Jones asks you about George’s Test, you confidently respond that
chiropractors perform this test to help determine the types of chiropractic
adjustments that are appropriate. The George’s Test also helps you
decide if additional testing is in order. This may help allay some of her
fears about the chiropractic adjustment.
Due to heightened concerns about stroke from cervical
manipulation, it is important to address this issue with the patient early
in your relationship. By doing this, you act proactively so that if Mrs
Jones’ friends express concern about seeing a chiropractor, she has a
positive reply. From our training, we know that the combination of
birth-control pills and smoking may raise the risk factors for stroke. In
George’s Test, we check bilateral blood pressure; auscultate and
palpate the subclavian and carotid arteries; and have the patient rotate
and extend her head on each side. The practitioner should rule out
dizziness, vertigo, bruits, and abnormal pulsations. Positive findings in
this testing require additional follow-up to rule out the possibility of
vertebrobasilar insult. If you are not familiar with this testing, it is
important that you learn this information for yourself and your patients.
As you conduct your examination, you engage Mrs Jones
in some light conversation designed to relax her and to solicit additional,
helpful information. When she mentions that she has two young children, you
talk to her briefly about daily ergonomics that may be contributing to her
pain. She admits that her 5-year-old daughter still likes to be carried and
Mrs Jones will often carry her on the right side so that her left hand is
free. This gives you an opportunity to test grip strength and muscle
function, where you are able to demonstrate a mild loss of strength on the
right upper extremity. Although her initial complaint involved the neck and
arm, you include testing for the rest of the body, knowing that dysfunction
in one area often leads to problems in another.
As you perform your orthopedic tests, Mrs Jones alludes
to the fact that periodically she experiences disabling back pain,
especially when she returns to the YMCA to “get in shape.” You
mention that she has a hyper-lordosis in her low back that may indicate a
dysfunctional relationship in her lumbar spine and the muscles around it.
If the underlying cause is not fixed, exercise may exacerbate the problem.
You broach the subject of the vertebral subluxation complex and explain
that you will discuss this in detail during the report of findings.
During the examination, because of the opening in the
back of the gown, you notice a small, suspicious-looking mole on the back
of her left shoulder. You mention that she may want to follow up with her
dermatologist just in case. You also notice that her nails are splitting
and her tongue is a beefy red color with tooth marks around the edges. As
you point these out, you ask her about diet and supplements. She says that
she often skips meals because she is dieting and tends to grab food on the
run. You mention that part of the healing process involves nutrition, and
that you may discuss this during the report of findings or during the
course of her care.
At the conclusion of the exam, Mrs Jones remarks on
how thorough your exam was. Although I am not advocating that we do the
22-page exam we had to do in chiropractic college, I am saying that we need
to do a thorough examination in a timely fashion that will provide us with
sufficient clinical information. As you give her the prescription for
x-rays, Mrs Jones seems much more relaxed and is eager to make a follow-up
appointment. You mention that her husband may wish to attend the report of
findings so that he understands what is happening.
Your examination has demonstrated that you are thorough
and will take the time necessary to get to the root of the problem. Your
insights during the exam showed her that you have a strong education
background as a chiropractor, including coursework in dermatology and
nutrition, on top of the essentials in biomechanics, posture, and function.
You have listened to her comments throughout the consultation and the
examination, so your questions were insightful and thought-provoking. You
have alluded to the subluxation and started to move the patient away from
referring to the adjustment as “cracking.”
As a result, you have created a strong foundation for
patient education that continues throughout the course of treatment. This
helps Mrs Jones know that she is in good hands, those of a doctor of
chiropractic.
A thorough initial exam includes questioning,
testing, and
educating the patient
Patient Education 
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