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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.