PHYSIOTHERAPY ASSESSMENT :

SUBJECTIVE :
NAME : Nithyashree
AGE : 16 years
GENDER : Female
IP/OP NO :
DATE OF ADMISSION : 01/11/2020
DATE OF EXAMINATION : 01/12/2020
OCCUPATION : Student
HAND DOMINANCE : Right
CHIEF COMPLAINTS :
By bystander – weakness , tiredness , unable to see & walk , vomiting
PRESENT HISTORY :
Patient was brought to emergency department on 1st December with complaints of fever &
vomiting , developed tiredness thereafter patient was admitted to ICU , intubated on 6th
November and was weaned off the ventilator and was shifted to paediatric ward on 18/11/2020 ,
patient developed cortical blindness in the ICU .
PAST HISTORY :
No significant past history
FAMILY HISTORY :
Not relevant
SOCIOECONOMIC HISTORY :

VITAL SIGNS :
TEMPERATURE : AFEBRILE
BP : 110/70
PR:
RR:
OBJECTIVE EXAMINATION
A) ON OBSERVATION :
Attitude of limbs :
Built :
Posture :
Gait :
Pressure sores :
B) ON PALPATION :
Warmth :
Tone :
C) ON EXAMINATION :
HIGHER MENTAL FUNCTIONS :
Level of consciousness : CONSCIOUS , ALERT & ORIENTED
Orientation :
Person :
Place :
Time :
Attention span :
ROM :
MOVEMENT RIGHT LEFT
SHOULDER FLEXOR
SHOULDER EXTENSOR
SHOULDER ABDUCTORS
SHOULDER ADDUCTORS
ELBOW FLEXORS
ELBOW EXTENSORS
WRIST FLEXORS
WRIST EXTENSORS
HIP FLEXORS
HIP EXTENSORS
HIP ABDUCTORS
HIP ADDUCTORS
KNEE FLEXORS
KNEE EXTENSORS
ANKLE DORSIFLEXORS
ANKLE
PLANTARFLEXORS

SENSORY SYSTEM :
SUPERFCIAL :
PAIN , TEMPERATURE , TOUCH , PRESSURE
DEEP :
PROPRIOCEPTION , POSITION SENSE , VIBRATION
CORTICAL :
TACTILE LOCALIZATION , TWO POINT DISCRIMINATION , STEREOGNOSIS ,
BAROGNOSIS , GRAPHESTHESIA , TEXTURE RECOGNITION , DOUBLE
SIMULTANEOUS STIMULATION :
VOLUNTARY CONTROL :
SIDE RT LT
UPPER LIMB
LOWER LIMB

CRANIAL NERVE EXAMINATION :

NERVES COMMENTS
OLFACTORY
OPTIC
OCCULOMOTOR
TROCHLEAR
TRIGEMINAL
ABDUCENT
FACIAL
VESTIBULOCOCHLEAR
GLOSSOPHARYNGEAL
VAGUS
ACCESSORY
HYPOGLOSSAL
MUSCLE TONE :
MUSCLE POWER :
MOVEMENT RIGHT LEFT
SHOULDER FLEXOR
SHOULDER EXTENSOR
SHOULDER ABDUCTORS
SHOULDER ADDUCTORS
ELBOW FLEXORS
ELBOW EXTENSORS
PRONATORS
SUPINATORS
WRIST FLEXORS
WRIST EXTENSORS
HIP FLEXORS
HIP EXTENSORS
HIP ABDUCTORS
HIP ADDUCTORS
KNEE FLEXORS
KNEE EXTENSORS
ANKLE DORSIFLEXORS
ANKLE
PLANTARFLEXORS

REFLEXES :
SUPERFICIAL :
ABDOMINAL
PLANTAR

DEEP:
BICEPS
TRICEPS
BRACHIORADIALIS
KNEE
ANKLE

COORDINATION :
DIADOKOKINESIA :
FINGER TO NOSE :
BALANCE :
SITTING :
Static :
Dynamic :
STANDING :
Static :
Dynamic :
INVESTIGATIONS :
PROBLEM LIST :
GOALS :
SHORT TERM :

LONG TERM :

PLAN OF TREATMENT :