SUBJECTIVE
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SUBJECTIVE Name____________________________________________________________ Age_________ Gender _________ Chief Complaint: L R _______________________________________________________________________ PMH: HTN Cholesterol Cardiac Diabetes _____________________________________________________________________________________________ PSH:__________________________________________________________________________________________ Family History: HTN Cholesterol Cardiac Diabetes Cancer_______________________________________ _____________________________________________________________________________________________ General Health Status: Smoke: ETOH: YES Excellent Good Fair Poor NO YES _______________________________________ Recent Infection: YES Night Pain: NO YES NO Bowel & Bladder Dysfunction: YES Cervical H/A: Dizziness: Nausea/Vomiting: Double Vision/Diploplia: Difficulty Swallowing: NO YES YES YES YES YES NO Thoracic/Cardiac (c/o L Arm Pain) Chest Pain: YES NO SOB: YES NO Pain with inspir/expir: YES NO NO NO NO NO NO (rib fx) Meds (Over the Counter):_________________________________________________________________________ Meds (Prescribed):______________________________________________________________________________ Occupation/Employment Status:___________________________________________________________________ Standing Sitting Bending Lifting Twisting Overhead Repetitive _____________________________________________________________________________________________ Recreational Activities:___________________________________________________________________________ Living Environment: Alone Family House Elevator _____________________________________________________________ Apartment Stairs _____________________________________________________ ________________________________________________________ Date of Onset:____________________________________ Duration of Sx:_________________________________ Why PT now:___________________________________________________________________________________ MOI: acute chronic sudden gradual __________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Limitations/Difficulties: Occupation Bed Mobility Transfers Ambulation Stairs _____________________________________________________________________________________________ Functional Status: cane r/w s/w w/c crutches _____________________________________________ Prior Level of Function:___________________________________________________________________________ Happened Before?: YES NO _________________________________________________________________ Previous Treatment:_____________________________________________________________________________ Other Health Care Seen:__________________________________________________________________________ MD Recommendation/Prescription:________________________________________________________________ Imaging: X-Ray MRI CT Scan _______________________________________________________________ Location of Symptoms:___________________________________________________________________________ Type of Pain: burning aching Constant numbness radiating dull sharp tingling Intermittent Pain Level: 0 1 2 3 4 5 6 7 8 9 10 CURRENT Pain Level: 0 1 2 3 4 5 6 7 8 9 10 AT BEST Pain Level: 0 1 2 3 4 5 6 7 8 9 10 AT WORST Aggravated by: Lifting Bending Twisting Stairs Ambulation Movement__________________________ _____________________________________________________________________________________________ Alleviated by: Rest Ice Heat Massage Position Change Meds _____________________________________________________________________________________________ How Sx Change Throughout the Day________________________________________________________________ How Sx Changed Since Initial Onset_________________________________________________________________ Handedness: Left Right Pt’s Goals:____________________________________________________________________________________ *Summarize hx Questions/Concerns_____________________________________________________________________________ Differential Diagnosis: 1. _________________________________________________ 2. _________________________________________________ 3. _________________________________________________ OBJECTIVE SYSTEM’S REVIEW CARDIOVASCULAR Heart Rate:____________________________ Blood Pressure:_________________________ Edema: _______________________________ INTEGUMENTARY Incision Clean and Dry Open Wound Infection Color________________ Temp___________________ _____________________________________________________________________________________________ Diabetic Feet Integumentary: Diabetic Feet Sensation: Diabetic Pedal Pulse: Intact Intact Intact Impaired Impaired Impaired NEUROMUSCULAR (pick upper or lower) Dermatomes C1- vertex of head C2- behind ear C3- lateral neck C4- upper trapezius C5-lateral deltoid C6- dorsum of thumb & index finger, lateral elbow, lateral forearm C7- dorsum of digit III C8- 4th & 5th fingers, ulnar aspect of hand, medial forearm T1- medial aspect of brachia L2- anterior proximal thigh L3- greater trochanter, medial aspect of knee L4- medial lower leg, knee L5- lateral lower leg, dorsum of foot S1- lateral aspect of foot S2- posterior medial thigh/leg Sensation: Reflexes: Intact Impaired ____________________________________________________________________ C5- biceps Symmetrical Diminished L R Hyperactive L R C6- brachioradialis Symmetrical Diminished L R Hyperactive L R C7- triceps Symmetrical Diminished L R Hyperactive L R L4- patellar Symmetrical Diminished L R Hyperactive L R S1- Achilles Symmetrical Diminished L R Hyperactive L R MUSCULOSKELETAL Myotomes (BREAK TEST: examine bilaterally; symptom reproduction w/ isometric contraction) Strong and Painless= Normal Strong and Painful= Minor contractile tissue lesion Weak and Painless= Complete rupture or gross neurological incidence; no sensory or motor Weak and Painful= Major contractile tissue lesion C1- cervical flexion C2- cervical extension C3- cervical lateral flexion C4-shoulder shrug C5- shoulder abduction C6-elbow flexion, wrist extension C7- elbow extension, wrist flexion C8- thumb abduction T1-finger abduction/adduction L2- hip flexion L3- knee extension L4- ankle DF/heel walking L5- great hallux extension S1- foot eversion/toe walking S2- Foot intrinsic UE AROM/Break Test: LE AROM/Break Test: Shoulder Flexion INTACT IMPAIRED L R Shoulder Abduction INTACT IMPAIRED L R Apley’s ER INTACT IMPAIRED L R Apley’s IR (T8-T4) INTACT IMPAIRED L R Elbow Flexion INTACT IMPAIRED L R Elbow Extension INTACT IMPAIRED L R Wrist Flexion INTACT IMPAIRED L R Wrist Extension INTACT IMPAIRED L R Grip INTACT IMPAIRED L R Hip Flexion INTACT IMPAIRED L R Knee Extension INTACT IMPAIRED L R Knee Flexion INTACT IMPAIRED L R Dorsiflexion INTACT IMPAIRED L R Plantarflexion INTACT IMPAIRED L R INSPECTION Anterior: R Shoulder Depressed R Lateral Shift L Shoulder Depressed L Lateral Shift None (depressed shoulder is dominant side) (shift of trunk relevant to pelvis) ASIS Position ____________________________________________________________________ Genu Varum Genu Valgum Patella Position: L R alta Navicular Height: Lateral: Symmetrical Forward Head L R L R baja L R squinting Asymmetrical Rounded Shoulders Kyphosis ASIS sup, PSIS inf = post rot ilium Accentuated Lordosis L R Decreased Lordosis ASIS inf, PSIS sup = ant rot ilium Genu Recurvatum Pes Cavus Posterior: Pes Planus Scoliosis Scapular Position: WNL Winging Iliac Crest Height: Symmetrical Dumping _____________________________________ L R Superior (posterior rotated ilium or upslip) PSIS Position_____________________________________________________________________ Calcaneal Alignment: Too Many Toes: Ambulation: Antalgic WBOS Circumduction L Eversion R Bilat Inversion___________________________________________ ___________________________________________________ Dec Stride Length Dec Heel Strike Toe Drag Shuffling Circumduction Hip-Hike _____________________________________________________________________________________________ UPPER QUARER SCREEN ROM: Cervical WNL Impaired OP/end-feel (if pain free) Flexion (0-50⁰) Extension (0-60⁰) SB R (0-45⁰) SB L (0-45⁰) Rot R (0-80⁰) Rot L (0-80⁰) Repeated Motions: (reproduction of symptoms) Tests: (perform if reproduction of symptoms to r/o disc problem) Compression Test (extend & SB): Distraction Test: + + - - LOWER QUARTER SCREEN ROM: Lumbar WNL Impaired Flexion (0-60⁰) Exension (0-25⁰) SB R (0-25⁰) SB L (0-25⁰) Rot R (0-45⁰) Rot L (0-45⁰) Repeated Motions: (reproduction of symptoms) Tests: (perform if reproduction of symptoms) Quadrant Test (extend, SB, rot): + - OP/end-feel (if pain free)
