Download - Assessment Technique
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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