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Principles Identification data/ Personal identification

Chief complaints

History Observation

Examination

Special tests

Investigations

Diagnosis

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Identification data Name

Age

Gender Occupation

Dominant side

Address

Etc..

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Chief complaints

This is the patient's symptom(s) in their own words and

should be no more than a single sentence.

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HistoryWhile history taking the questions should start with

open ended and then progress to closed ended type.

H/O present illness H/O past illness

Medical history

Family history

Personal history

Social history

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ObservationsIt starts as the patient enter the assessment area.

Look for:-

Body alignment

Any obvious deformity Bony contours

Soft tissue contours

Skin & nail color, texture etc.

Symmetry

Any scar

Facial expression

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Examination Inspection (looking)

Palpation (Feeling)

Percussion (tapping)Auscultation (listening)

OR

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Ortho Examination framework Look

Feel

MoveActive

Passive

Measure

Special tests

functions

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Palpation Difference in the tissue tension and texture

Difference in the tissue thickness

Abnormality Tenderness

Temperature and its variation

Pathological state of tissues

Dryness or excessive moisture

Abnormal sensations

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MoveActive movements

Passive movements

End feel Capsular patterns

Resisted movements

Isomteric

Isotonic

Joint play movements

Joint crepitus, snapping and abnormal sounds.

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Measure ROM

MMT

Limb length and girthADLS

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Functional assessmentThrough direct assessment and questionaires

Barthels index

Katz index SF36

FIM

FMS etc..

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Neural ExaminationIt includes the examination of complete nervous system

starting from central to peripheral nervous system tillreceptors and effectors.

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Neural Examination Framework Inspection, mood and conscious level

Speech and higher mental functions.

Cranial nerves.

Motor system.

Reflexes

Sensation.

Co-ordination. Gait.

Any extra tests.

Other relevant examinations.

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Investigations Radiographic

X-rays

MRI

CT Scans

Ultrasound

EMG

NCV EEG

ECG

Echocardiography

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Lab investigations

Exercise testing/stress testing

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Diagnosis