GENERAL FORMAT FOR ORTHOPEDIC ASSESSMENT

SUBJECTIVE ASSESSMENT
Name : (To know the identity of the patient.) Age : (To determine age related problems, e.g. Osteoarthritis, carpal tunnel syndrome) Sex : (To determine sex-related problems) Occupation : (To determine occupation-related problems, e.g. Tennis Elbow) IC No. / IP No. / OP No. : (For records) Address : (Incase theres an emergency/ for further contacts)

 Chief complaint:(no medical terminology. Purely in patients word) History o Present history:(the examiner should ask the mechanism of the injury, so he can determine the structure which were injury & how severe of the patients injuries.) o Past history:(the examiner should ask to the patient whether the similar condition has occurred before.) o Medical history:(medicines the patient has been taking) Personal history:(alcohol/smoking/drugs) Family history:(the examiner should ask if anybody in the family has the same or similar problem.eg. rheumatoid arthritis) Surgical history:(whether the patient ever experience the surgical treatment before).

 Vital Signs : - Blood Pressure : (120/80 mm of Hg) - Pulse rate: (72-90 Beats per minute) - Temperature : (37C /98.6F) - Respiratory rate:(15-20 breaths per min) (The examiner should check all the vital signs because a patient with high temperature is contraindicated for certain modalities of therapy. Also hypertension patients should not be given heavy exercises.)

 Pain History :

o o o o

Side : (Right/ Left) Site : (A-P/ S-I) Onset : ( Sudden / Gradual ) Duration : ( Acute/ Chronic - Chronic pain is often associated with multiple factors such as fatigue or certain postures or activities.) o Aggravating Factors : Factors which increase pain, eg. Walking, running, etc. o Relieving Factors : Factors which relieve the pain, eg. Sitting down, etc.

o Type of Pain :
PAIN DESCRIPTION Cramping, dull, aching Dull, aching Sharp shooting, radiating Sharp, Bright, lightning-like, radiating Burning, pressure-like, stinging, aching Deep, nagging, dull Sharp, severe, intolerable Throbbing, diffused RELATED STRUCTURE Muscle Ligament, Capsule Nerve Root Nerve Sympathetic nerve
Bone Fracture Vasculature

o Visual analog scan (vas)

Therapist ask the patient stage of pain.
moderate Mild 0 1 2 3 4 5 6 7 8 9 10 Severe

O to 4: mild pain 5 to 6: moderate pain 7 to 10: severe pain

OBJECTIVE ASSESSMENT
ON OBSERVATION:

Built: (endomorph/mesomorph/ectomorph)

 Skin Condition: The therapist must see any changes of the skin in the area of the pain and look for the scars or open wounds, check for the texture of skin, It can be dry/scaly/supple.

SCARS

OPEN WOUND

DRY SKIN

SUPPLE SKIN

SCALY SKIN

Edema : (pitting or non pitting edema) Deformities : (abnormal position of the joint and limb, for example: scoliosis,kyophosis and lordosis) Gait : > Independent > Dependent on wheel chairs External appliances : (cannula,catheter,canes,walking aids)

PROSTHOSIS An artificial body parts

ORTHOSIS Devices applied to human limb to control or prevent bone move

 ON PALPATION
Tenderness : (pain on touch).
Grades of Tenderness : 0 - No tenderness. 1 Tenderness with palpation WITHOUT grimace/ flinch. 2 Tenderness with grimace/flinch on palpation. 3 Tenderness with withdrawal. 4 Withdrawal (+Jump sign) to non-noxius stimuli.

Edema : (pitting / non pitting). Warmth : (it is tested by using dorsal side of hand to get know the temperature level).

 ON EXAMINATION

Motor Examination
(1) RANGE OF MOTION (ROM)
The range of motion is taken both active (physiological) and passive (physiological and accessory). Compare with opposite limb. It is measured from 0 degree and it is also measured first before the passive. The degree is to which a joint can be moved by muscle contraction. The movement is classified as : Hypomobile (Decreased ROM) Normal Hypermobile (Increased ROM)

 ACTIVE ROM
It is physiological movement such as flexion,extension,abduction,adduction,external and internal rotation,dorsiflexion,etc. The movement is done by the patient here. Active movement is limited by several condition such as joint pain, joint stiffness, muscle weakness, pain from nearby fracture site and soft tissues.

PASSIVE ROM
It is a physiological movements such as flexion, extension, abduction, adduction, internal and external rotation, etc. The movement is done by the therapist here.

(2) STRENGTH
The muscle strength is determined by manual muscle testing (MMT). The muscle grading is then done according to the tests. It is able to generate force against some resistance. Muscle grading chart tests through the range. MUSCLE GRADE 0 Nil 1 Trace/Flicker 2 Poor 3 Fair 4 Good DESCRIPTION No evidence of contraction Slight contraction, but no joint motion Complete ROM with gravity eliminated Complete ROM against gravity Complete ROM against gravity with some resistance

5 Normal

Complete ROM against gravity with full resistance

 Reflexes:
Reflex is a mechanism by which sensory impulse is automatically converted to motor effect through the involvement of CNS (1) Deep Tendon Reflexes are performed to test the integrity of the spinal reflexes. (2) Superficial reflexes are motor responses to scraping of the skin.

Deep Tendon Reflexes

REFLEX Jaw Biceps Patella SITE OF STIMULUS Mandible Biceps tendon Patellar Tendon NORMAL RESPONSE Mouth closes Biceps contracts Knee extension CNS SEGMENT Mid pons C5-C6 L3-L4

Achilles

Achilles Tendon

Plantar flexion of foot

S1-S2

 Deep Tendon reflexes are graded as follows : 0 Absent (LMN Paralysis) 1- Present (Normal Response) 2- Brisk 3- Exaggerated (UMN Paralysis) 4- Clonus

 Superficial reflexes :
REFLEX Corneal Reflex NORMAL RESPONSE Brief closing of the eyelids by involuntary normal periodic closing Umbilicus moves down and towards area being stroked Flexion of toes CNS SEGMENT C5-C7

Umbilical Reflex Plantar

T11-T12 S1-S2

 Superficial Reflexes are graded simply as present or absent, although markedly asymmetrical responses should be considered abnormal as well.

 Sensory Examination :
[TO BE DONE ONLY IN CASES OF SPINAL CORD INJURIES, DISC PROLAPSE INJURIES ONLY]

(1) Superficial Sensation : Pain Touch Temperature (2) Deep Sensation Deep Pressure Kinesthesia Proprioception (3) Cortical Sensation Two Point Discrimination Graphesthesia Stereognosis

Limb Girth measurement

The limb girth measurement is to measure the upper and lower limb. It is measured to see the muscle wasting and the level of effusion around the joint.

Limb Length measurement

The limb length measurement consist of 2 types: a) True Length- measured from the ASIS to the medial malleolus. b) Apparent Length- measured from the Umbilicus to the medial malleolus. By taking measurement from both legs to get the different or shortening of the limb.

FUNCTIONAL ASSESSMENT
Dependent / partially dependent / independent. Investigations : X-ray (bone only) bone changes or fractures. MRI Scan ( Magnetic Resonance Imaging)- more features, can see bone, muscles, soft tissues, ligaments, tendons. CT Scan (Computed tomography)- can see visceral only ( organs, muscles). Bone scan- scanning whole bodys bone, for bone cancer, stress fracture, hairline fracture. Total blood count- RBC, WBC, Platelets.

 Diagnosis : Determination on causes of symptoms, and solution to the disease or condition. Differential Diagnosis : Likely Possibly, high stakes Possible, low stakes Unlikely Special test : Neurodynamic mobility examination. Positive if there is present of neuropathic dysfunction include pain, parasthesia and spasm. Problem List : Obvious problem that affect patient. Positive and negative findings.

 Goals of Treatment : Achieving positivity of treatment. To improve life. Short Term Goal What is possibly achieved in short term. To decrease acute condition. Reduce pain and inflammation. Long Term Goal What is to be achieved in long term. To increase ROM, muscle strength. Treatment : Procedures to be carried out to overcome patients problem.