Professional Documents
Culture Documents
I.
Subjective Assessment
Marital Status: -
Gender: -
Mode of Admission: -
Presenting Complaint: -
HOPC: ____________________________________________________________________________________
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Treatment History:
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Family History:
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Socioeconomic History:
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Symptoms History:
- Side:
- Site:
- Onset:
- Duration:
- Type:
- Severity:
- Aggravating Factors:
- Relieving Factors:
Vital Signs:
- Temperature:
- Blood Pressure:
II.
- Heart Rate:
- Respiratory Rate:
Objective Examination:
a) ON OBSERVATION:
- Attitude of limbs:
- Built:
- Posture:
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- Gait: ______________________________________________________________
- Pattern of Movement:_________________________________________________
- Mode of Ventilation:__________________________________________________
- Type/ Pattern of Respiration:___________________________________________
- Oedema: ___________________________________________________________
- Muscle Wasting: _____________________________________________________
- Pressure Sores:______________________________________________________
- Deformity:_________________________________________________________
- Wounds:___________________________________________________________
- External Appliances: ________________________________________________
b) ON EXAMINATION
HIGHER MENTAL FUNCTIONS
Level of Consciousness:_______________________________________________________
Orientation: ______________________________________
- Person:________________________________
- Place:_________________________________
- Time:__________________________________
Memory:
- Immediate:__________________________________
- Recent:______________________________________
- Remote:_____________________________________
Speech:____________________________________________________________________
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Cognition:
Cranial Nerves:
Nerves
Comments
I - Olfactory
II - Optic
III - Oculomotor
IV - Trochlear
V - Trigeminal
VI - Abducent
Nerves
Comments
VII - Facial
VIII - VestibuloCochlear
IX - Glossopharyngeal
X - Vagus
XI - Accessory
XII - Hypoglossal
SENSORY SYSTEM:
Upper
Extremity
Location
Sensation
Rt
Lt
Lower
Extremity
Rt
Lt
Trunk
Rt
Comments
Lt
Superficial
Pain
Temperature
Touch
Pressure
Deep
Mov. Sense
Pos. Sense
Vibration
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Cortical
Tactile Localization
2 pt. discrimination
Stereognosis
Barognosis
Graphesthesia
Texture Recognition
Double
Simultaneous
Stimulation
MOTOR SYSTEM:
Muscle Girth:
Area
Rt
Lt
Arm
Forearm
Thigh
Calf
Voluntary Control:
Side
Rt
Lt
Upper Limb
Lower Limb
Myotomes: -
Myotomes Root
C1/C2
C3
C4
C5
C6
C7
C8
T1
L2
L3
L4
L5
S1
S2
Function
neck flexion/extension
neck lateral flexion
shoulder elevation
shoulder abduction
elbow flexion/wrist extension
elbow extension/wrist flexion
thumb extension
finger abduction
hip flexion
knee extension
ankle dorsi flexion
great toe extension
ankle plantar flexion
knee flexion
Comment
Range of Motion:
Side
Upper Limb
Rt
Lt
Lower Limb
Limb Length:
Side
Rt.(cm.)
Lt.(cm.)
True
Apparent
Muscle Tone:
Muscles
Shoulder
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Elbow
Flexors
Extensors
Forearm
Pronators
Supinators
Wrist
Flexors
Extensors
Radial Deviators
Ulnar Deviators
Hand
Intrinsics
Extrinsics
Rt
Lt
Muscles
Hip
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Knee
Flexors
Extensors
Ankle
Dorsiflexors
Plantarflexors
Foot
Invertors
Evertors
Intrinsics
Extrinsics
Remarks:
Rt
Lt
Muscle Power:
Muscles
Shoulder
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Elbow
Flexors
Extensors
Forearm
Pronators
Supinators
Wrist
Flexors
Extensors
Radial Deviators
Ulnar Deviators
Hand
Intrinsics
Extrinsics
Rt
Lt
Muscles
Hip
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Knee
Flexors
Extensors
Ankle
Dorsiflexors
Plantarflexors
Foot
Invertors
Evertors
Intrinsics
Extrinsics
Rt
Lt
Trunk Flexors
Trunk Extensors
Trunk Side Flexors
Trunk Rotators
Reflexes:
Superficial
Deep
Reflex
Abdominal
Plantar
Right
Left
Biceps
Brachioradialis
Triceps
Knee
Ankle
Coordination:
Non Equilibrium Tests
Finger to nose
Finger opposition
Mass Grasp
Pronation/Supination
Rt
Lt
Equilibrium tests
Standing: Normal Posture
Standing: Normal Posture with
vision occluded
Standing: Feet together
Rebound test
Tapping (Hand)
Tapping (Foot)
Tandem walking
Heel to knee
Drawing a circle (Hand)
Drawing a circle (Foot)
Grade
Walk: Sideways
Walk: Backward
Walk in Circle
Walk on Heels
Walk on Toes
Involuntary Movements:
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Balance:
- Sitting:__________________________________________________________________
- Standing:________________________________________________________________
- Balance Reactions:________________________________________________________
Posture:
- Lying:_________________________________________________________________
- Sitting:________________________________________________________________
- Standing:_______________________________________________________________
Gait:
Step Length:_____________________________________________________________
Stride Length:____________________________________________________________
Base width:______________________________________________________________
Cadence:________________________________________________________________
Biomechanical Deviations:__________________________________________________
Hand Functions:
- Reaching:_______________________________________________________________
- Grasping:_______________________________________________________________
- Releasing:_______________________________________________________________
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Assistive Devices:
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III.
Systems Review:
INTEGUMENTARY SYSTEM:
Skin Color _________________________ Skin Texture _________________________
Scar Formation _____________________ Skin Integrity _________________________
Pressure Sores: ________________________________________________________________
RESPIRATORY SYSTEM:
Dyspnea
Yes/No
Sputum
Yes/No ______________________
Hemoptysis
Yes/No
Stridor
Yes/No
Wheezing
Yes/No
Yes/No
Pattern of breathing:____________________________________________________________
Chest wall/Thoracic spine deformity:______________________________________________
CARDIOVASCULAR SYSTEM:
Dyspnea
Yes/No
Orthopnea
Yes/No
Palpitations
Yes/No
Pain/Sweats
Yes/No
Syncope
Yes/No
Peripheral Edema
Yes/No
Cough
Yes/No
Resting/Exertional (Mild/Moderate/Severe)
Yes/No
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MUSCULOSKELETAL SYSTEM:
Contractures: __________________________________________________________
Subluxations:__________________________________________________________
Joint mobility: _________________________________________________________
Other pathology: _______________________________________________________
BLADDER & BOWEL FUNCTIONS:
Incontinence: ___________________________________________________________
GASTROINTESTINAL SYSTEM:
Difficulty with Swallowing
Yes/No
Heartburn/Indigestion
Yes/No
Change in appetite
Yes/No
Yes/No
AUTONOMIC SYSTEM
Vasomotor: ________________________________________________________________
Trophic Changes: ___________________________________________________________
Postural Hypotension: _______________________________________________________
Reflex Sympathetic Dystrophy: _______________________________________________
IV.
Item 1. Food
Item 2. Care of appearance
Item 3. Hygiene
Item 4. Dressing upper body
Item 5. Dressing lower body
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
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Evaluation 3: Mobility
Yes/No
Yes/No
Yes/No
Evaluation 4: Locomotion
Yes/No
Yes/No
Evaluation 5: Communication
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Investigation Findings:
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Problem List:
S#
Impairment
Functional Limitation
Functional Diagnosis:
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V.
Management
Goals
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