2. Subjective Examination
1. Name
2. Age
3. Sex
4. Occupation
5. Address
6. Date of admission
7. Date of injury
8. Post medical history
9. Date of surgery
10. Present medical history
11. Family and social history
12. Personal history
13. Psychological history
14. Vital signs
• Temperature – 37c, 98f
• Pulse rate – 80-120 beats/min
• Respiratory rate – 15-20 breaths/min
• Blood pressure – 120/80 mmHg
3. 15. Obstetric history
• Natal – Duration of labor
Nature of labor
• Neonatal – Premature
Birth weight
• Family history – Number of children
Order of the subject
Other affected children
• Post natal – Any infection
16. Constitutional Symptoms
• Fever
• Loss of appetite
• Loss of weight
17. Associated problems
• Diabetes mallitus
• Hypertension
• Tuberculosis
4. Objective Examination
• On observation/general appearance, posture, gait, handedness of patient.
• General Appearance
• Built – Obese, lean, musculature, moderate, height.
• Facial expression
• Skeletal deformities
• Abnormal size of head
• Observe skin (for coloration, scar, skin disease, surgical sutures, pressure sores)
• Muscles
• Oedema
• Observe on involuntary movements
• Handedness
• Mode of ambulation
• Any external appliances
• Attitude of limb
5. On Examination
• 1 - Assessment Of Higher Function
1 - Orientation – time, place, person, memory, recent and remote consciousness.
2 – Emotional State – (anxious, excited, depressed, frightened.)
(conscious, orientation, memory, language, general intelligence.)
• 2 - Cranial Nerve Assessment
Reflexes
• 3 - Musculoskeletal Assessment
Power
Tone
Bulk
RIGHT LEFT
UPPER LIMB
LOWER LIMB
6. • 4 - Assessment Of Sensation
1 – Exteroceptive Sensation/Superficial
Pain, touch, temperature
2 – Proprioceptive Sensation/Deep
Position sense
Sense of passive movement, vibration sense, deep pain.
3 – Cortical Sensation
Tactile localization, two point discrimination
Graphasthesia (ability to recognise writing on skin purely by the sensation)
Barognosis (ability to evaluate the weight of the touch of object)
Sterognosis (ability to perceive the form of solid object by touch)
4 – Perceptive Sensation
Agnosia (visual tactile & auditory)
Apraxia (a motor disorder caused by damage to brain)
Aplasia (a language disorder that affects persons ability to communicate)
8. • 6 – Range Of Motion
Active & passive ROM
• 7 – Deformity
• 8 – Analysis Of Balance
Static balance
Dynamic balance
• 9 – Assessment Of Posture
Anterior
Posterior
• 10 – Gait Assessment
Step length
Stride length
Arm length
Cadence
• 11 – Assess The Coordination
Non-equilibrium
Equilibrium
Non-equilibrium Equilibrium
Finger to nose Rhomberg test
Rebound test Standing feet together
Heel to skin Standing on one leg
9. • 12 – Bladder & Bowel Function
• 13 – Functional Assessment ADL (Barthel & Katz index)
Bathing – bed mobility
Dressing – feeding – ambulation
Going to toilet
• 14 – Investigation
• 15 – Problem List
• 16 – Aim
To improve ambulation
To correct posture
• 17 - Treatment
