ORTHOPEDIC

ASSESSMENT

SUBMITTED TO-
Dr. Sheela Durai,
Professor & HOD,
Surgical Nursing,
College of Nursing,
CMC, Vellore.

SUBMITTED BY-
Ms. Joice Das,
M.Sc. Nursing (1st year),
College of Nursing,
CMC, Vellore.

DATE OF PERFORMANCE-
DEMOGRAPHIC DATA

Name - Mr. Badal Sarkar

Age - 59 years
IP Number - 570452P
DOA - 09/12/2021
Ward -Q2
Diagnosis - Lumbar canal stenosis
Proposed surgery - Lumbar spine decompression

PERSONAL HISTORY

Bowel - Once a day

Bladder - 4-5 times a day
Sleep - Sleeps adequately for 6-7 hours in the night
Habits - He has the habit of drinking alcohol. Left drinking since 10-15 days
Allergy - He is not allergic to any food and medications
Activities - He walks 3 kms per day.

FAMILY HISTORY

Type of family - Nuclear

Type of marriage - Non- consanguinous
No. of children - 2 children
History of family illness – Nil
Family history of orthopedic anomalies- No history of congenital anomalies in the family

SOCIO-ECONOMIC STATUS

Occupation - Contractor. He climbs 2-4 sets of stairs every day

Education - Has completed his higher secondary education
Type of house -Pucca house
Water facility -Tap and borewell
Electricity - Has adequate lighting facility at home
Ventilation - Has adequate windows and doors
Total income - Earns Rs. 30,000- 50,000 per month
Socio-economic status- Upper- middle class
Health Insurance- Nil
PAST MEDICAL/SURGICAL HISTORY-

He is a known case of Ischemic heart disease and Diabetes mellitus-II and is on medication
Tablet Metformin 1 gm OD, Tablet Glimipride 2 mg OD, Tablet Tenegliptin 20 mg OD, Tablet
Ramipril 2.5 mg OD, Tablet Carvedilol 3.125 mg OD.
No history of trauma, fall, fever, chronic cough, loss of apetite and loss of weight.

PRESENTING COMPLAINTS-

He was apparently well before 5 years, after which he developed back pain which was
insidious in onset, gradually progressive, dull aching type of pain, radiating to his bilateral
lower limbs, started with left lower limb initially and then right since 1 month. Pain
aggravates on walking and relieved by rest and mediations. He visited a local hospital where
he was given analgesics and physiotherapy was started for him but his pain did not subside.
He came to CMC, Vellore for further management.

PHYSICAL EXAMINATION-

GENERAL APPEARANCE

Mr. Badal Sarkar, moderately built, wheatish brown in complexion. He was able to stand in
neutral position. He was not on any supportive device.

Pallor- Absent
Icterus- Absent
Clubbing- Absent
Cyanosis- Absent
Lymphadenopathy- Absent
Edema- Absent

SR Parameters Pts. Value Normal Value Remarks

1. Blood pressure (mmHg) 130/90 120/90 Within normal ranges
2 Pulse rate (bts/min) 78 80-100
3 SPO2(%) 100% 99-100
4 Respiratory 18 15-20
Rate(brts/min)
VITAL SIGNS
MUSCULOSKELETAL EXAMINATION

Local Examination

No scars, no sinuses, dilated veins or visible pulsation. No neurocutaneous markers, no

warmth, tenderness present on lower limbs. No paraspinal muscle spasm.

Range of Motion

Range of motion of lumbar spine is full but terminally painful.

LEFT RIGHT
Straight Leg Raise Test 90 degree 90 degree
Lasegue test More than 75 degree causes pain

Muscle Power

Hip abduction 5/5

Hip adduction 5/5
Hip flexion 5/5
Hip extension 5/5
Knee flexion 5/5
Knee extension 5/5
Ankle dorsiflexion 5/5
Ankle plantar flexion 5/5

SENSATION

L2 Intact
L3 Intact
L4 Intact
L5 Intact
S1 Intact
S2 Intact

Perianal sensation intact.

REFLEXES

Knee joint ++ ++
Ankle joint ++ ++
Anal tone Intact

GAIT

Pattern- Normal gait cycle. Begins at the heel strike of one foot and continues until the heel
strike of the same foot in preparation for the next step and consists of the stance phase and
the swing phase. 

Functional Gait assessment

1. Gait on a Level Surface- Walks 6m in less than 5.5 seconds with no aids, in good speed and
no evidence of imbalance. Also deviates no more than 15.24cm (6in) outside of the walkway
width.

2. Change in Gait Speed- Able to smoothly change walking speed without loss of balance or
gait deviation. Shows a significant difference in walking speeds between normal, fast, and
slow speeds. Deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway
width.

3. Gait with Horizontal Head Turns- Performs head turns smoothly with no change in gait.
Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in)
walkway width.

4. Gait with Vertical Head Turns- Normal, performs head turns with no change in gait.
Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.

5. Gait and Pivot Turn-  Pivot turns safely in 3 seconds and stops with no loss of balance, or
pivot turns safely within 3 seconds and stops with mild imbalance, requires small steps to
catch balance.

6. Step Over Obstacle- He is able to step over 2 boxes (22.86 cm [9 in] total height) without
changing gait speed; no evidence of imbalance.

7. Gait with Narrow Base of Support- Ambulates 7–9 steps.

8. Gait with Eyes Closed- Walks 6 m (20 ft), no assistive devices, good speed,no evidence of
imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-
in) walkway width. Ambulates 6 m (20 ft) in less than 7 seconds.

9. Ambulating Backwards- Walks 6 m (20 ft), no assistive devices, good speed,no evidence for
imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-
in) walkway width.

10. Stairs- Two feet to a stair; must use rail.

CONCLUSION

Mr. Badal Sarkar, 59 year old man