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Orthopaedic Physiotherapy Assessment Chart for Physiotherapists by Dr. Krishna N. Sharma

Orthopaedic Physiotherapy Assessment Chart for Physiotherapists by Dr. Krishna N. Sharma

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Orthopedic Physiotherapy Assessment Chart for Physiotherapists designed by Dr. Krishna N. Sharma. You can use this chart to assess your patient and condition.
Orthopedic Physiotherapy Assessment Chart for Physiotherapists designed by Dr. Krishna N. Sharma. You can use this chart to assess your patient and condition.

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Published by: Dr. Krishna N. Sharma on Apr 05, 2009
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07/17/2015

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Orthopaedic Assessment

§
-Designed ByDr. Krishna N. Sharma

§

§
-PublicationOnline Physio Community, India
Web: http://www.opcindia.info.ms E-Mail: dr.krisharma@gmail.com
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Orthopaedic Assessment
Name :

Age : Address: Chief Complaints:

Gender:

Occupation:

Present History:  Mode of Onset:  Duration:  Associated Problem: Past Medical History:  Birth History:  History of other diseases & injuries:  Operations & Hospitalizations:  Medications:  Physiotherapy Treatment: Personal History:  Personal Habits:  Marital Status: Family History:  Similar Problem in relatives:  Hereditary Diseases:  Consanguinity:  Infections: Economical History:  Income:  Source: Social History:  Social Status:  Educational Status: Environmental History:  Environment of Home:  Environment of Workplace:

Expenditure:

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Vital Signs:  Heart Rate:  Blood Pressure: General Observation:  Built:  Posture:  Gait: o Antalgic Gait: o Ataxic Gait: o Calcaneal Gait: o Circumductory Gait: o Hand to Knee Gait: o High Stepping Gait: o Jack Knifing Gait: Local Observation:  Inflammation:  Swelling:  Scar:

 

Temperature: Respiratory Rate:

o Lordotic Gait: o Scissoring Gait: o Talus Gait: o Trendlenburg Gait: o Valgus Gait: o Varus Gait: o Waddling Gait: o Other: Deformities:

  

Skin Condition: Muscle Wasting: Shape Alteration:

Palpation:  Swelling: Pitting, Non-Pitting  Tenderness: GradeⅠ/ Grade Ⅱ/ Grade Ⅲ/ Grade Ⅳ  Warmth:  Crepitus:  Scar: Heal / Non-Heal / Length Sensory Examination:  Superficial Sensations: o Pain:  Nature:  Mode of Onset:  Course (If Radiates):  Aggravating Factors:  Relieving Factors:  Visual Analogue Scale: 0 1 2 3 4 5 6 7 8 9 10

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o Touch: Normal, Anesthesia, Hyperesthesia, Hypoesthesia o Temperature:  Hot Test Tube (40-45∘C):  Cold Test Tube (5-10∘C):  Deep Sensations: o Propioception: o Kinesthesia: Cortical Sensations: o Graphesthesia: o Stereognosis: Superficial Reflexes: o Corneal Reflexes: o Abdominal Reflexes:  Epigastric Region (T7-T9):  Upper Abdominals (T9-T11):  Lower Abdominals (T11-T12): o Cremastric Reflex (L1-L2): o Anal Reflex (S4-S5): o Planter Reflex: Deep Tendon Reflexes: o Biceps (C5-C6): o Brachioradialis (C5-C6): o Triceps (C7-C8): o Pectoral (C5-T1): o Finger Flexion (C6-T1):

o Vibrations:

o Tactile Localization: o 2 Point Discrimination:

o o o o o

Knee (L3-L4): Post. Tibial (L4-L5): Med Hamstring (L5-S1): Lat. Hamstring (S1–S2): Ankle (S1–S2):

Range of Motion: Joint Rt.(Active) Lt.(Active) Rt.(Passive) Lt.(Passive) End Feel

Pain

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Muscle Power: Muscle

Rt.

Lt.

Limb Length: Rt. True Apparent   Pelvic Square: Segmental Limb Length: Rt. Humeral Ulnar Femoral Tibial Muscle Girth: Rt. Arm Forearm Quadriceps Calf Balance:  Static: o Sitting (With eyes open & closed) o Standing (With eyes open & closed) o Tendem Standing (With eyes open & closed)  Dynamic: 0 – Unable to do 1 – With Human Support 2 – Using Aid 3 – Needs Supervision 4 - Independent Lt. Lt. Lt.

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o Reaching out activities: Able/Unable o Perturbation: Able/Unable Gait Analysis:  Stance Phage:  Swing Phage:  Step Length:  Stride Length: Functional Evaluation of Upper Limb:  Dressing:  Combing:  Washing:  Eating:  Toileting:  Other: Functional Evaluation of Lower Limb:  Stair Climbing:  Cycling:  Other: Investigations:  Pathological Findings:  Radiological Findings:

  

Base Width: Cadence: Other:

1 - Total Assistance Patient- <25%, Assistant- >75% 2 - Max. Assistance Patient- 25%, Assistant- 75% 3 - Moderate Assistance Patient- 50%, Assistant- 50% 4 - Minimal Assistance Patient- 75%, Assistant- 25% 5 - Supervision Cues without physical contact 6 - Modified Independence Assistive devices, takes more time 7 - Completely Independent

Special Tests:

Differential Diagnosis: Diagnosis: Physiotherapy Aims:  To relieve pain  To increase ROM  To correct the deformity  To relieve stiffness  To improve muscle power & strength

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      

To improve muscle endurance To maintain tissue extensibility To correct posture To improve balance To train for walking aids Gait training Other

Short Term Goals:

Long Term Goals:

Physiotherapy Plan:

HEP (Home Exercise Program):

Ergonomics:

Instructions by the Therapist:

Date of Evaluation:

Therapist

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