The first step towards being a good physical therapist ,is to be able to assess the patient holistically .Let us begin with the assessment part.
NEUROLOGICAL ASSESSMENT
DEMOGRAPHIC DATA:this information helps the therapist to maintain records and communicate effectively with the patient .
NAME ASSESSED BY
AGE DATE
SEX
OCCUPATION
ADDRESS
WARD NO
BED NO
O.P.D NO
I.P.D NO
DATE OF ADMISSION
CHIEF COMPLAINT: This is the single most important complaint of the patient.
RELATIVE COMPLAINTS:These are related to chief complaint.A patient with only one complaint is a rare phenomena.
HISTORY OF PRESENT ILLNESS:This is a detailed explanation given by the patient,regarding the onset, time, duration,frequency, severity,etc. of the existing complaint.
PAST MEDICAL HISTORY: Only relevant history that relates to the existing complaint should be noted.For instance,history of hypertension in a CVA/ stroke patient.
PAST SURGICAL HISTORY: Relevant surgical history within the span of one decade can usually be considered important.For instance,any surgery over the face may cause facial palsy later ,due to injury to the facial nerve.
DRUG HISTORY: To know if patient has been using some drugs for long term,for a condition.This sometimes can be of vital importance in case of stroke,which can be caused by unsupervised discontinuation of anti-hypertensives.
FAMILY HISTORY: Helps to know the prevalence of heriditory conditions in the family which could also be present in the patient.
PERSONAL HISTORY:
SLEEP: To know if the complaint disturbs patient's sleep.And helps to know patient's sleeping habits and sleep hygine.
APPETITE: To know if the appetite is reduced .
BOWEL/BLADDER: To know of existing incontinence , and hence, catheterization of the patient.
ADDICTIONS:Smoking, alcohol or other drugs abused by patients should be known.
SOCIAL AND ECONOMIC STATUS: It is important to know if the family is supportive or not , and if the patient can afford the treatment in case of long-term illness patients.
RELEVANT HISTORY:This is a skillfully drawn conclusion by the therapist, regarding the probable cause of the complaint , on basis of history alone.
GENERAL EXAMINATION: Physical therapy interventions are contra-indicated if the patient's vitals are very unstable or outside the normal range.
BLOOD PRESSURE :
PULSE RATE :
RESPIRATORY RATE:
BODY TEMPERATURE:
ATTITUDE OF THE PATIENT:
SPECIFIC NEUROLOGICAL EXAMINATION:
HIGHER CORTICAL FUNCTIONS
CONSCIOUSNESS :Measured using Glasgow Coma Scale(GCS)
ORIENTATION : to time , place and person.
SPEECH: affected in conditions like Parkinsonism , Motor neuron disease, etc.
MEMORY:Recent and past memory tested to rule out amnesia.
VISION:can be impaired if optic nerve is affected.
HEARING: can be impaired if vestibulo-cochlear nerve is affected.for instance, tinnitus can be present.
UNDERSTANDING AND REASONING:absence of which leads to more dependence of the patient.
CRANIAL NERVE TESTING: all the 12 cranial nerves have to be tested.
MOTOR EXAMINATION:
TONE:Hypertonia/hypotonia should be noted . spasticity if present , can be measured using Modified Ashworth scale .
VOLUNTARY CONTROL: measured by vlountary control grade in case of upper motor neuron lesions
MUSCLE POWER: measured by manual muscle testing in case of lower motor neuron lesions.
REFLEXES: tested with a reflex hammer.They can be exaggerated, brisk , normal or diminished.
PLANTAR REFLEX/BABINSKI'S SIGN:
SUPERFICIAL REFLEXES: abdominal reflex .
DEEP TENDON REFLEXES: biceps jerk, triceps jerk, bracioradialis , knee jerk,ankle jerk ,etc
PRIMITIVE /NEONATAL REFLEXES:Moro's reflex, ATNR,STNR,TLR,etc
BALANCE AND CO-ORDINATION
BALANCE:static and dynamic balance is tested using various tools like Romberg's sign , with eyes open ,closed and tandem walk position.
CO-ORDINATION TESTSfinger-finger, finger-nose, heel-shin, heel-toe, etc.
SENSATIONS: tested with patient in supine lying position and eyes preferably closed. best response is obtained when tested from distal to proximity.They can be present , absent or abnormal.
SUPERFICIAL SENSATIONS: fine touch, pain , temperature,tactile localozation , tactile discrimination.
DEEP SENSATIONS: crude touch,deep pressure, vibrations.
COMBINED CORTICAL SENSATIONS:kinaesthetic sensations, joint proprioception, stretch, stereognosis.
GAIT ASSESSMENT: make the patient walk independently if he/she can.abnormal gait patterns should be noted. step length, stride length,cadence step width, etc should be measured.
FUNCTIONAL ASSESSMENT: using Barthel index of FIM's score
PROVISIONAL DIAGNOSIS: this is 75% of diagnosis derived by the therapist on basis of above information and assessment.
DIFFERENTIAL DIAGNOSIS: these are other possible diagnoses which can be ruled out after investigations.
INVESTIGATIONS: MRI of the brain , CT scan of brain ,etc
DIAGNOSIS: this is the conclusive diagnosis of patient's existing problems.
ICIDH2 :
STRUCTURAL IMPAIRMENT:
FUNCTIONAL IMPAIRMENT:
ACTIVITY LIMITATIONS:
PARTICIPATION RESTRICTIONS:
POSITIVE CONTEXTUAL FACTORS:
NEGATIVE CONTEXTUAL FACTORS:
PROBLEM LIST OF PATIENT:
SHORT TERM GOALS:
LONG TERM GOALS:
MANAGEMENT:
AIMS: set up by the therapist which can be achieved by proper intervention
MEANS: to achieve the above aims.
NEUROLOGICAL ASSESSMENT
DEMOGRAPHIC DATA:this information helps the therapist to maintain records and communicate effectively with the patient .
NAME ASSESSED BY
AGE DATE
SEX
OCCUPATION
ADDRESS
WARD NO
BED NO
O.P.D NO
I.P.D NO
DATE OF ADMISSION
CHIEF COMPLAINT: This is the single most important complaint of the patient.
RELATIVE COMPLAINTS:These are related to chief complaint.A patient with only one complaint is a rare phenomena.
HISTORY OF PRESENT ILLNESS:This is a detailed explanation given by the patient,regarding the onset, time, duration,frequency, severity,etc. of the existing complaint.
PAST MEDICAL HISTORY: Only relevant history that relates to the existing complaint should be noted.For instance,history of hypertension in a CVA/ stroke patient.
PAST SURGICAL HISTORY: Relevant surgical history within the span of one decade can usually be considered important.For instance,any surgery over the face may cause facial palsy later ,due to injury to the facial nerve.
DRUG HISTORY: To know if patient has been using some drugs for long term,for a condition.This sometimes can be of vital importance in case of stroke,which can be caused by unsupervised discontinuation of anti-hypertensives.
FAMILY HISTORY: Helps to know the prevalence of heriditory conditions in the family which could also be present in the patient.
PERSONAL HISTORY:
SLEEP: To know if the complaint disturbs patient's sleep.And helps to know patient's sleeping habits and sleep hygine.
APPETITE: To know if the appetite is reduced .
BOWEL/BLADDER: To know of existing incontinence , and hence, catheterization of the patient.
ADDICTIONS:Smoking, alcohol or other drugs abused by patients should be known.
SOCIAL AND ECONOMIC STATUS: It is important to know if the family is supportive or not , and if the patient can afford the treatment in case of long-term illness patients.
RELEVANT HISTORY:This is a skillfully drawn conclusion by the therapist, regarding the probable cause of the complaint , on basis of history alone.
GENERAL EXAMINATION: Physical therapy interventions are contra-indicated if the patient's vitals are very unstable or outside the normal range.
BLOOD PRESSURE :
PULSE RATE :
RESPIRATORY RATE:
BODY TEMPERATURE:
ATTITUDE OF THE PATIENT:
SPECIFIC NEUROLOGICAL EXAMINATION:
HIGHER CORTICAL FUNCTIONS
CONSCIOUSNESS :Measured using Glasgow Coma Scale(GCS)
ORIENTATION : to time , place and person.
SPEECH: affected in conditions like Parkinsonism , Motor neuron disease, etc.
MEMORY:Recent and past memory tested to rule out amnesia.
VISION:can be impaired if optic nerve is affected.
HEARING: can be impaired if vestibulo-cochlear nerve is affected.for instance, tinnitus can be present.
UNDERSTANDING AND REASONING:absence of which leads to more dependence of the patient.
CRANIAL NERVE TESTING: all the 12 cranial nerves have to be tested.
MOTOR EXAMINATION:
TONE:Hypertonia/hypotonia should be noted . spasticity if present , can be measured using Modified Ashworth scale .
VOLUNTARY CONTROL: measured by vlountary control grade in case of upper motor neuron lesions
MUSCLE POWER: measured by manual muscle testing in case of lower motor neuron lesions.
REFLEXES: tested with a reflex hammer.They can be exaggerated, brisk , normal or diminished.
PLANTAR REFLEX/BABINSKI'S SIGN:
SUPERFICIAL REFLEXES: abdominal reflex .
DEEP TENDON REFLEXES: biceps jerk, triceps jerk, bracioradialis , knee jerk,ankle jerk ,etc
PRIMITIVE /NEONATAL REFLEXES:Moro's reflex, ATNR,STNR,TLR,etc
BALANCE AND CO-ORDINATION
BALANCE:static and dynamic balance is tested using various tools like Romberg's sign , with eyes open ,closed and tandem walk position.
CO-ORDINATION TESTSfinger-finger, finger-nose, heel-shin, heel-toe, etc.
SENSATIONS: tested with patient in supine lying position and eyes preferably closed. best response is obtained when tested from distal to proximity.They can be present , absent or abnormal.
SUPERFICIAL SENSATIONS: fine touch, pain , temperature,tactile localozation , tactile discrimination.
DEEP SENSATIONS: crude touch,deep pressure, vibrations.
COMBINED CORTICAL SENSATIONS:kinaesthetic sensations, joint proprioception, stretch, stereognosis.
GAIT ASSESSMENT: make the patient walk independently if he/she can.abnormal gait patterns should be noted. step length, stride length,cadence step width, etc should be measured.
FUNCTIONAL ASSESSMENT: using Barthel index of FIM's score
PROVISIONAL DIAGNOSIS: this is 75% of diagnosis derived by the therapist on basis of above information and assessment.
DIFFERENTIAL DIAGNOSIS: these are other possible diagnoses which can be ruled out after investigations.
INVESTIGATIONS: MRI of the brain , CT scan of brain ,etc
DIAGNOSIS: this is the conclusive diagnosis of patient's existing problems.
ICIDH2 :
STRUCTURAL IMPAIRMENT:
FUNCTIONAL IMPAIRMENT:
ACTIVITY LIMITATIONS:
PARTICIPATION RESTRICTIONS:
POSITIVE CONTEXTUAL FACTORS:
NEGATIVE CONTEXTUAL FACTORS:
PROBLEM LIST OF PATIENT:
SHORT TERM GOALS:
LONG TERM GOALS:
MANAGEMENT:
AIMS: set up by the therapist which can be achieved by proper intervention
MEANS: to achieve the above aims.
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