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Subjective
Basic data:
Name:
Age :
Gender:
Occupation:
Date of admission:
Date of onset:
Date of PT starting:
Impression:
PT intervention:
Past history:
Family disease history:
CT/X-ray:
Other medical problem:
Vital sign:
(
Brief history(��ltla1):
Objective
1. Consciousness :
2. Mentality (JOMAC): / // (N: normal, I: impaired)
3. Communication:
[1 P't is able to express himself/herself
[1 P't has difficulty or is unable to express
himself/herself[1 P't has difficulty understanding language
and directions[1 Remark

4. General observation:
(1) Posture(if)
(i)Sitting in W/C:
*anterior view
*lateral view
*posterior view
(2 Sitting in bed:
*anterior view
*lateral view
*posterior view
3. Standing:
*anterior view
*lateral view
*posterior view
(2) Edema:
*hand:
*Foot:
(3) Swallowing:
(4) Color of extremity:
*UE
*LE
 (5) Vision field(if):
(6) Hearing:
(7) Facial palsy(if):
5. Palpation:
(1) Pain: (+)(shoulder pain)
(2) temperature of extremity :
(3) subluxation :
(4) RSD:
Sensation:
Superficial sensations and Combined cortical sensations
C P t
(2: normal, 1: impair, 0: absent)
Pin prick Localization
L't R't L't R't
UE Shoulder
Elbow
Forearm
Hand
LE Hip
Knee
Ankle
Summary:
Proprioception
(2: normal, 1: impair, 0: absent)
Static Dynamic
L't R't L't R't
UE Shoulder
Elbow
Wrist
LE Hip
Knee
Ankle
Summary:
ROM
L't R't
PROM End-feel PROM End-feel
Shoulder flexion(165-
180)
Shoulder
extension(50-60)
Shoulder
abduction(170-180)
Elbow flexion(140-
150)
Elbow extension
Wrist flexion(60-75)
Wrist extension(60-
80)
Wrist pronation(75-
85)
Wrist supination(80-
90)
Hip flexion(120-140)
Hip extension(side-
lying)
Hip abduction(40-50)
Hip adduction(20-25)
Knee flexion(130-140)
Ankle dorsiflexion(15-
20)
Ankle
plantarflexion(40-55)
Summary:

Muscle tone: Evaluated from Modified Ashworth scale for grading spasticity
(N:normal/hypertone/hypotone) (spasticity/rigidity) (MAS: 0 1 1+ 2 3 4)
L't R't
UE Shoulder Flexor
Extensor
Elbow Flexor
Extensor
Wrist Flexor
Extensor
LE Hip Flexor
Extensor
Knee Flexor
Extensor
Ankle Plantarflexor

Dorsiflexor

Summary:

MMT
L't R't

Shoulder Flexor

Shoulder Extensor

Shoulder Abductor

Elbow Flexor

Elbow Extensor
 Wrist Flexor

Wrist Extensor

Hip Extensor

Hip Flexor

Hip Abductor

Hip External rotator

Hip Internal rotator

Knee Extensor

Knee Flexor

Ankle Dorsiflexor

Ankle Plantarflexor

*: May be underestimated because he perform in elimited gravity position .

Summary:

Brunnstrom stage:
Brunnstrom stage
Involved side ( right
)
Upper extremity
Lower extremity

Upper limb, motor assessment

A. Stage 1 (Presynergy stage): Present Absent
1. Flaccidity (hypotone)
B. Stage 2: (Spasticity) Present Absent
1. Associated movements
C. Stage 3 (Synergy stage):

1. Flexion components Grading

a. Shoulder girdle elevation
b. Shoulder girdle retraction

c. Shoulder joint hyperextension

 d. Shoulder joint abduction
e. Shoulder joint external rotation
f. Elbow flexion
g. Forearm supination
2. Extension components Grading
a. Shoulder protraction, adduction, internal rotation
b. Elbow extension
c. Forearm pronation
D. Stage 4 (Movements Deviating From Basic Synergies): Grading
1. Hand to sacrum
2. Raise arm forward to horizontal
3. Pronation (Elbow flexed)
4. Supination (Elbow flexed)
E. Stage 5 (Relative Independence of Basic Synergies): Grading
1. Raise arm to side-horizontal
2. Supination (Elbow extended)
3. Forward reach from horizontal
4. Raise arm over head
F. Stage 6 (isolated joint movements): Present Absent
1. Stage 5 full points

Lower limb, motor assessment

A. Stage 1 (Presynergy stage): Present Absent
1. Flaccidity (hypotone)
B. Stage 2: (Spasticity) Present Absent
1. Associated movements
2. Raimiste's abduction
3. Raimiste's adduction
C. Stage 3 (Synergy stage):
1. Flexion components (supine) Grading
a. Hip flexion
b. Hip abduction & external rotation
c. Knee flexion

d. Ankle dorsiflexion
2. Extension components (side lying) Grading
a. Hip extension
b. Hip adduction & internal rotation
c. Knee extension
d. Ankle plantar flexion
D. Stage 4 (Movements Deviating From Basic Synergies): Grading
 1. Hip unilateral abduction (supine)
2. Hip flexion, acute angle (sitting)
3. Knee flexion, acute angle (sitting)
4. Ankle dorsiflexion, acute angle (sitting)
5. Knee extension (sitting)
E. Stage 5 (Relative Independence of Basic Synergies): Grading
1. Ankle dorsiflexion (standing, knee extension)
2. Ankle inversion & eversion (sitting)
3. Isolated knee flexion (standing)
F. Stage 6 (isolated joint movements): Present Absent
1. Stage 5 full points

Hand assessment
. Stage 1: Present Absent
1. Flaccidity (hypotone)
B. Stage 2: Present Absent
1. Spasticity (Little or no active finger
flexion)
C. Stage 3: Grading
1. Mass Grasp
. Stage 4: Grading
1. Lateral prehension & Release
2. semi-voluntary finger extension
. Stage 5: Grading
1. Palmar prehension
2. Cylindrical and spherical grasp
3. Voluntary mass extension of digits
F. Stage 6 isolated joint movements : Present Absent
1. Stage 5 full points

Coordination
Upper limb- alternate nose to finger
Speed (times/10sec) times
Performance
Lower limb- heel to shin
Speed (times/10sec) times
Performance
Summary:
 Balance
Balance reaction:( )
Push to R't Push to L't
Reaction
*Performance
*we have not challenged patients to the point where neck and trunk righting is
required
Sitting balance:
Static Dynamic
Balance
Performance
Standing balance:
Static Dynamic
Para-standing
Performance
Romberg's test:
Summary:

Functional mobility:(independent, supervision, close guarding, minimum assist,

moderate assist, maximum assist)

Performance
Rolling to R 't
Rolling to L 't
Weight shifting in sitting
Scooting(to edge, side to side)
Bridging

Supine � sitting/lying on R 't

Supine � sitting/lying on L
't:
Sitting � standing
bed to W/C
Summary:

Gait analysis and ambulation

Walking speed:

Parallel bar Elbow flexed

Cane Arm hangs flaccidly

Supported Swing near normal

Alone

Affected Foot Analysis With brace

Without brace
Short steps with Normal
foot

Even steps

nkle stance phase nkle swing phase

Entire sole down Toes drag

Toes first Exag. dorsiflex.

Inversion, early stance Near Normal

Inversion throughout

Valgus on mid-stance

Near normal heel-toe

Knee Stance phase Knee swing phase

Buckles Stiff

Hyperextension Moderate stiff

Stable in flexion Exag. flexion

Near normal Near normal

Hip Stance phase Hip Swing phase

Trendelenburg Circumduction

Trunk forward Ext. rotation

Steady, near normal Pelvic hike

Exag. flexion

Near normal

FIM
Self Care

A. Eating

B. Grooming

C. Bathing

D. Dressing-upper body

E. Dressing-lower body

F. Toileting
 Sphincter control

G. Bladder management

H. Bowel management

Transfers

I. Bed, chair, wheelchair

J. toilet

K. tub, shower

Locomotion

L. Walk/wheelchair

M. Stairs

Motor Subtotal Score

Communication

N. Comprehension

O. Expression

Social cognition

P. Social Interaction

Q. Problem solving

R. Memory

Cognitive Subtotal Score

TOT L FIM SCOR 126

35/91 35/35 Total FIM Score 70/126,
Problem list
Short term goal (2-3 weeks)