CASE:

SUBJECTIVE ASSESSMENT:
• NAME:
• AGE:
• GENDER:
• ADDRESS:
• Ph. No:
• OCCUPATION:
• CHIEF COMPLAINTS:

• HISTORY:
o PAST HISTORY:

o PRESENT HISTORY:

o PERSONAL HISTORY:

o FAMILY HISTORY:

o MEDICAL HISTORY:
 o SURGICAL HISTORY:

o PT HISTORY:

o SOCIOECONOMIC HISTORY:

OBJECTIVE ASSESSMENT:
• HAND DOMINANCE:
 Right
 Left

• VITALS:
 Temp:
 PR:
 BP:
 RR:

• OBSERVATION:
 Built of the patient:
 Position of the patient:
 Attitude of the limbs:

JOINT RIGHT LEFT

SHOULDER
ELBOW
WRIST
FINGERS
HIP
KNEE
ANKLE
SUBTALAR
TOES
  Breathing pattern:
 Facial symmetry:

 Deformities:

 External appliances:

 Skin observation:

 Posture:

 Gait:

• PALPATION:

• EXAMINATION:
 Consciousness:

 Higher mental functions:

 Speech:
 Orientation:
 Memory:
 Intelligence:
 Behavior:
 Cranial Nerve Examination:

 I - Olfactory nerve:
 II - Optic nerve:
 III –Occulomotor nerve:
 IV - Trochlear nerve:
 V - Trigeminal nerve/dentist nerve:
 VI - Abducens nerve:
 VII - Facial nerve:
 VIII - Vestibulocochlear nerve/Auditory nerve:
 IX - Glossopharyngeal nerve:
 X - Vagus nerve:
 XI - Accessory nerve/Spinal accessory nerve:
 XII - Hypoglossal nerve:

 Sensory System Examination:

 Superficial senses:
➢ Touch:
➢ Pain:
➢ Temperature:
➢ Pressure:
 Deep senses:
➢ Vibration:
➢ Proprioception:
➢ Kinesthetic sensation:
 Cortical senses:
➢ Tactile localization:
➢ Tactile discrimination:
➢ Sterognosis:
➢ Graphesthesia:
➢ Double simultaneous sensation:
➢ Texture discrimination:

 Motor System Examination:

 Tone:
 Bulk:
 ROM:
 Strength:
 Limb length:
  Reflex System Examination:
 Superficial reflexes:
➢ Abdominal:
➢ Plantar:
➢ Corneal:
 Deep reflexes:
➢ Jaw jerk:
➢ Biceps jerk:
➢ Triceps jerk:
➢ Patellar jerk:
➢ Achillis tendon jerk:

 Posture:

 Balance:

 Coordination:

 Gait:

 ADL Examination:

INVESTIGATIONS:
PROBLEM LIST:

TREATMENT PLAN:

DAY WISE MANAGEMENT PROTOCOL: