general format for orthopedic assessment

8/13/2019 General Format for Orthopedic Assessment

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GENERAL FORMAT FOR

ORTHOPEDIC ASSESSMENT


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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 furthercontacts)


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Chief complaint:(no medical terminology. Purely in patients

word)

Historyo 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 whetherthe 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 thefamily has the same or similar problem.eg. rheumatoid

arthritis)

Surgical history:(whether the patient ever experience the

surgical treatment before).


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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.)


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Pain History :

o Side : (Right/ Left)

o Site : (A-P/ S-I)

o Onset : ( Sudden / Gradual )

o Duration : ( Acute/ Chronic - Chronic pain is often associated

with multiple factors such as fatigue or certain postures oractivities.)

o Aggravating Factors : Factors which increase pain, eg. Walking,

running, etc.

o

Relieving Factors : Factors which relieve the pain, eg. Sittingdown, etc.


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o Type of Pain :

PAIN DESCRIPTION RELATED STRUCTURE

Cramping, dull, aching Muscle

Dull, aching Ligament, Capsule

Sharp shooting, radiating Nerve Root

Sharp, Bright, lightning-like,

radiating

Nerve

Burning, pressure-like, stinging,

aching

Sympathetic nerve

Deep, nagging, dull Bone

Sharp, severe, intolerable Fracture

Throbbing, diffused Vasculature


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o

Visual analog scan (vas)

Therapist ask the patient stage of

pain.

Mild Severe

0 1 2 3 4 5 6 7 8 9 10

moderate

O to 4: mild pain

5 to 6: moderate pain

7 to 10: severe pain


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OBJECTIVE ASSESSMENT

ON OBSERVATION:

Built: (endomorph/mesomorph/ectomorph)


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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 bedry/scaly/supple.

SCARS OPEN WOUND


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DRY SKIN SCALY SKINSUPPLE SKIN


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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)


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PROSTHOSIS

An artificial body parts

ORTHOSIS

Devices applied to humanlimb to control or preventbone move


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ON PALPATION

Tenderness : (pain on touch).

Grades of Tenderness :

0 - No tenderness.

1Tenderness with palpation WITHOUT grimace/ flinch.

2Tenderness with grimace/flinch on palpation.

3Tenderness with withdrawal.4Withdrawal (+Jump sign) to non-noxius stimuli.

Edema : (pitting / non pitting).

Warmth : (it is tested by using dorsal side of hand to getknow the temperature level).


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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)


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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 ROMIt is a physiological movements such as flexion, extension, abduction,

adduction, internal and external rotation, etc.

The movement is done by the therapist here.


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(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 charttests through the range.

MUSCLE GRADE DESCRIPTION

0Nil No evidence of contraction

1Trace/Flicker Slight contraction, but no joint motion2Poor Complete ROM with gravity

eliminated

3Fair Complete ROM against gravity

4Good Complete ROM against gravity withsome resistance

5Normal Complete ROM against gravity with

full resistance


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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.


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Deep Tendon Reflexes

REFLEX SITE OFSTIMULUS

NORMAL RESPONSE CNSSEGMENT

Jaw Mandible Mouth closes Mid pons

Biceps Biceps tendon Biceps contracts C5-C6

Patella Patellar Tendon Knee extension L3-L4

Achilles Achilles Tendon Plantar flexion of foot S1-S2


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Deep Tendon reflexes are graded as follows :

0Absent (LMN Paralysis)1- Present (Normal Response)

2- Brisk

3- Exaggerated (UMN Paralysis)

4- Clonus


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Superficial reflexes :

REFLEX NORMAL RESPONSE CNS SEGMENT

Corneal Reflex Brief closing of the eyelids by

involuntary normal periodic

closing

C5-C7

Umbilical Reflex Umbilicus moves down and

towards area being stroked

T11-T12

Plantar Flexion of toes S1-S2


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Superficial Reflexes are graded simply as present or absent,

although markedly asymmetrical responses should be

considered abnormal as well.


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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


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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.


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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.


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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.


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Diagnosis :Determination on causes of symptoms, and solutionto 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.


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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.

general format for orthopedic assessment

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