Anda di halaman 1dari 7

Orthopaedic Assessment

§
-Designed By-
Dr. Krishna N. Sharma

§
-Publication-
Online Physio Community, India
Web: http://www.opcindia.info.ms
E-Mail: dr.krisharma@gmail.com

© http://www.opcindia.info.ms Page 0 of 6
Orthopaedic Assessment

Name :
Age : Gender: Occupation:
Address:
Chief Complaints:

Present History:
 Mode of Onset:
 Duration:
 Associated Problem:

Past Medical History:


 Birth History:
 History of other diseases & injuries:
 Operations & Hospitalizations:
 Medications:
 Physiotherapy Treatment:

Personal History:
 Personal Habits:
 Marital Status:

Family History:
 Similar Problem in relatives:
 Hereditary Diseases:
 Consanguinity:
 Infections:

Economical History:
 Income:  Expenditure:
 Source:

Social History:
 Social Status:
 Educational Status:

Environmental History:
 Environment of Home:
 Environment of Workplace:

© http://www.opcindia.info.ms Page 1 of 6
Vital Signs:
 Heart Rate:  Temperature:
 Blood Pressure:  Respiratory Rate:

General Observation:
 Built: o Lordotic Gait:
 Posture: o Scissoring Gait:
 Gait: o Talus Gait:
o Antalgic Gait: o Trendlenburg Gait:
o Ataxic Gait: o Valgus Gait:
o Calcaneal Gait: o Varus Gait:
o Circumductory Gait: o Waddling Gait:
o Hand to Knee Gait: o Other:
o High Stepping Gait:  Deformities:
o Jack Knifing Gait:

Local Observation:
 Inflammation:  Skin Condition:
 Swelling:  Muscle Wasting:
 Scar:  Shape Alteration:

Palpation:
 Swelling: Pitting, Non-Pitting
 Tenderness: GradeⅠ/ Grade Ⅱ/ Grade Ⅲ/ Grade Ⅳ
 Warmth:
 Crepitus:
 Scar: Heal / Non-Heal / Length

Sensory Examination:
 Superficial Sensations:
o Pain:
 Nature:
 Mode of Onset:
 Course (If Radiates):
 Aggravating Factors:
 Relieving Factors:
 Visual Analogue Scale:

0 1 2 3 4 5 6 7 8 9 10

© http://www.opcindia.info.ms Page 2 of 6
o Touch: Normal, Anesthesia, Hyperesthesia, Hypoesthesia
o Temperature:
 Hot Test Tube (40-45∘C):
 Cold Test Tube (5-10∘C):

 Deep Sensations:
o Propioception: o Vibrations:
o Kinesthesia:

 Cortical Sensations:
o Graphesthesia: o Tactile Localization:
o Stereognosis: o 2 Point Discrimination:

 Superficial Reflexes:
o Corneal Reflexes:
o Abdominal Reflexes:
 Epigastric Region (T7-T9):
 Upper Abdominals (T9-T11):
 Lower Abdominals (T11-T12):
o Cremastric Reflex (L1-L2):
o Anal Reflex (S4-S5):
o Planter Reflex:

 Deep Tendon Reflexes:


o Biceps (C5-C6): o Knee (L3-L4):
o Brachioradialis (C5-C6): o Post. Tibial (L4-L5):
o Triceps (C7-C8): o Med Hamstring (L5-S1):
o Pectoral (C5-T1): o Lat. Hamstring (S1–S2):
o Finger Flexion (C6-T1): o Ankle (S1–S2):

Range of Motion:
Joint Rt.(Active) Lt.(Active) Rt.(Passive) Lt.(Passive) End Feel Pain

© http://www.opcindia.info.ms Page 3 of 6
Muscle Power:
Muscle Rt. Lt.

Limb Length:
Rt. Lt.
True
Apparent

 Pelvic Square:
 Segmental Limb Length:
Rt. Lt.
Humeral
Ulnar
Femoral
Tibial

Muscle Girth:
Rt. Lt.
Arm
Forearm
Quadriceps
Calf

Balance: 0 – Unable to do
 Static: 1 – With Human Support
o Sitting (With eyes open & closed) 2 – Using Aid
o Standing (With eyes open & closed) 3 – Needs Supervision
o Tendem Standing (With eyes open & 4 - Independent
closed)
 Dynamic:

© http://www.opcindia.info.ms Page 4 of 6
o Reaching out activities: Able/Unable
o Perturbation: Able/Unable

Gait Analysis:
 Stance Phage:  Base Width:
 Swing Phage:  Cadence:
 Step Length:  Other:
 Stride Length:

Functional Evaluation of Upper Limb: 1 - Total Assistance


 Dressing: Patient- <25%, Assistant- >75%
 Combing: 2 - Max. Assistance
 Washing: Patient- 25%, Assistant- 75%
 Eating: 3 - Moderate Assistance
 Toileting: Patient- 50%, Assistant- 50%
 Other: 4 - Minimal Assistance
Patient- 75%, Assistant- 25%
Functional Evaluation of Lower Limb: 5 - Supervision
 Stair Climbing: Cues without physical contact
 Cycling: 6 - Modified Independence
 Other: Assistive devices, takes more time
7 - Completely Independent
Investigations:
 Pathological Findings:

 Radiological Findings:

Special Tests:

Differential Diagnosis:

Diagnosis:

Physiotherapy Aims:
 To relieve pain
 To increase ROM
 To correct the deformity
 To relieve stiffness
 To improve muscle power & strength

© http://www.opcindia.info.ms Page 5 of 6
 To improve muscle endurance
 To maintain tissue extensibility
 To correct posture
 To improve balance
 To train for walking aids
 Gait training
 Other

Short Term Goals:

Long Term Goals:

Physiotherapy Plan:

HEP (Home Exercise Program):

Ergonomics:

Instructions by the Therapist:

Date of Evaluation: Therapist

© http://www.opcindia.info.ms Page 6 of 6

Anda mungkin juga menyukai