PHYSIOTHERAPY ASSESSMENT

SUBJECTIVE ASSESSMENT:
Demographic data: a. Name: b. Age: c. Gender: d. Weight: e. Occupation: f. Address: g. Phone no: CHIEF COMPLAINTS: Right lower leg and foot swollen and painful since previous evening.

HISTORY
Presenting history of illness: Past history of illness: Present and past medical history: analgesics Associative diseases: diabetes,

HTN. Duration: 3.pain agrevating factors: any weight bearing acticities. Type: Dull and aching Radiating 6.pain relieving factors: rest 8 Intensity of pain: a. site/location: ankle and foot 4.adl·s 7. Mode: Constant 5. obesity Family history: diabetic history Personal history: smoker Chronic alcoholic Socio Economic history: normal PAIN ASSESMENT: 1.Onset: Gradual 2. Visual analougus scale (vas) .

|-----------------------------------------------------| 0 7 10 OBJECTIVE ASSESMENT: 1. TEMPERATURE : warmth TENDERNESS : present (grade 3) OEDEMA : In right leg PULSE : bounding pedal pulse ON EXAMINATION: i.SWELLING : around foot and ankle .ATTITUDE OF LIMB : slightly in knee flexion .DEFORMITY : bowing out of plantar surface . ii.GAIT : 2. ON PALPATION i. iii. SENSORY EXAMINATION: A.GENERAL BODY POSTURE .BODY BUILT : normal (mesomorphic) . Superficial sensations .Touch: Fine touch . iv.REDNESS . ON OBSERVATION: .

Sterognosis . Cortical sensation: .Barognosis .Kinaesthesia .Graphestesia ii. Deep sensation: . Manual muscle testing: UPPER LIMB: 5 LOWER LIMBHip: Flexion : 3 Extension : 3 .Proprioception .vibration C. Muscle tone: b.Temperature B.Pain: .Tactile localization .2point discrimination: . MOTAR EXAMINATION: a.Crude touch .

1cm 23.2cm R 42cm 23.Abduction : 3 Adduction : 3 Knee: Flexion : Extension : Ankle: Dorsi Flexion Plantar flexion Inversion Eversion RANGE OF MOTION: MUSCLE GIRTH:- Girth measurements Calf Ankle L 41.4cm .

ct.LIMB LENGTH DISCREPANCY (LLD) TENDON REFLEXES Knee reflex : 1 ankle reflex : 1 ACTIVITIES OF DAILY LIFE: unable to squat INVESTIGATIONS: . mri.scan) - DIFFERENTIAL DIAGNOSIS: SPECIAL TESTS: PROVISIONAL DIAGNOSIS: LIST OF PROBLEMS: .LAB DIAGNOSIS (Enzymatic levels) RADIOLOGICAL INVESTIGATIONS (x-ray.

potential for amputation.TREATMENT PLAN: Aims .Appearance of the foot: ‡ Color : red ‡ Nails : ‡ Symmetry ‡ Swelling : ‡ Deformities .. : to correct muscular imbalances by increasing strength & decreasing contractures of specific muscles Prevention of further jt destruction and foot deformity To provide rest and stabilisation of the area PHYSIOTHERAPY INTERVENTIONS: FOOT ASSESSMENT 1. : yes 2.Prior history of foot ulcer? ‡ Is there an ulcer now?In the past? : no ‡ Is there a previous amputation? : no ‡ Pt is at risk for developing another foot ulcer.

Assess Circulation: ‡ Pedal pulses : bounding ‡ Temperature fluctuations : increased ‡ Atrophy : .Assess the skin: ‡ Absence of hair ‡ Thin/shiny skin ‡ Calluses ‡ Ulcers 4.3.

Assess Sensation ‡ Quick test .5.2 mins ‡ Painless ‡ Predicts potential ulcer development 6.Inspect Patient·s Footwear: Old and new shoes should be checked daily for‡ -nails/sharp objects ‡ -spots caused by open injuries .

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