By

Dr.Ada Anjumn

Name:

Age/Sex:

Occupation:

Address:

Contact No:

Marital Status:

Chief Complaint:

Case sheet study:

History

Present illness

- Mental

- Sleep

- Speech

Aphasia

Dysphonia

Dysarthria

Dyslexia

Dysgraphia

- Attack of Loss of Consciousness

- Headache

Duration

- Special part of the day

Character

Situation

- Tenderness

- Visual disturbances

- Vomitting

- Vertigo

- Any injury of the head

- Cough/ Sneeze effect

Visual disorder:

- onset

- frequency

- duration

Motor Disorders

- lack of coordination

- weakness – Proximal/ distal

- involuntary movement

- relieving factor

- precipitating factor

Sensory disorders:

- onset

- duration

- frequency

- Pain

- numbness/tingling

- site

- relieving factor

- precipitating factor

Spinchtor disorders

- onset

- duration

- frequency

- difficulty in control for incontinence / retention

- anal control

- bladder control

Pain history:

- Site

- Side

- Duration

- Type

- Nature

- Radiation

- Aggravating factor

- Relieving factor

Past History:

- convulsion

- meningitis

- infection

- enchaphalitis

- pneumonia

- jaundice - General developmental delay

- trauma/accident

- Hge - Malnutrition

Family History:

- consanguity

- epilepsy

- disability

- cardiovascular disorders

- inflammation

- Rh Factor

Development History

- eye contact

- social smile

- head control

- side turning

- sitting

- rolling

- crawling

- standing

- walking

Socio-economical history

- education

- occupation carrier

- tobacco

- cigaratte

- alcohol

Medical history

- drug allergy

Surgical History:

- incision

- length

- duration

- procedure

Physiotherapy treatment:

- Aims

- Means

- Duration

- Place

Objective Examination:

On Observation:

General

- Built

- Posture

- Gait

- Deformity

- Facial expression

Local:

- Oedema

- Atrophy

- Scar / incision / wound

- Cyanosis - Clubbing

- Neurological grafts - Breathing type

- Eye movement - Drains

- Ventilators - Fluid input / output

- Instrumentation

- Monitoring - catheterization

- Ryles tube - Tracheostomy

ON PALPATION

- Texture – Dryskin / scaly / smmoth

- Warmth

- Scar

- type of edema pitting / non pitting

- Spasm

- deformity rigid / flexible

- tone --. Hypo / hyper

- swelling –sessile / pedunculated

- anterior fontenelle

ON EXAMINATION

General:

Vital signs

- BP

- temperature

- Respiratory rate

- Heart rate

Glasgow coma scale

Eye Response

Spontaneously 4

To verbal stimuli 3

To pain 2

Never 1

Motor Response

Obeys command 6

Localizes pain 5

Flexion – withdrawl 4

Abnormal flexion 3

Abnormal extension 2

No response 1Verbal Response

Oriented 5

Disoriented 4

Inappropriate words 3

Incomprehensive words 2

No response 1

Cognitive skill

- Listen to language

- Understanding simple / complex commands

- Name objects

- Read correctly

- write correctly

- numerical calculation

- recognize objects

- dress himself

- copy geometric pattern

Intellectual function

- Orientation

- memory

- level of memory

Emotional state

- personal type

- emotional state

- slowness of movement

Speech

- Articulation

- Aphasia

Memory

- Short term memory

- long term memory

- recent memory

- remote memory

Cranial Nerve examination

Olfactory Smell

Optic

- Visual acquity

- visual field

- pupil

Occulomotor

- pupil

- occular movements

- nystagmus

Trigeminal nerve

- Jaw reflex

- Corneal reflex

- motor chewinh and clenching

- sensory opthalmic, maxillary and mandibular

Facial

- Moter Blinking, blowing, frowning, smiling, raising of eye brow

- taste Anterior 2/3rd of tongue

Vestibulocochlear

- Weber test and Rinne test conductive / neural defect

- Vestibular test caloric and hallpike test

Glossopharyngeal

- Gag reflex

- Taste of posterior 1/3rd of tongue

Vagus

- swallowing

- observe uvula and soft palate (asymmetry)

Accessory

- SCM

- Trapezius

Hypoglossal

- Tongue movements

- atrophy - deviation

MOTOR SYSTEM

Muscle tone Hypotone / Hypertone (Acc. to Modified Asworth Scale)

Inspection of muscle:

Circumference

- Thigh

- calf

- Arm

- forearm

Wasting

Hypertrophy

-Drooping of shoulder

-- FAsciculations

-- Joint ROM (For each joints)

-Reflexes

Superficial

-- Abdominal

- Plantar

Deep

-- Biceps - Brachioradialis

-- Triceps - Quadriceps

-- Hamstrings - Tendoachilus

Sensory Examination

Superficial sensation

- light touch - Temperature

- Pressure - pain

Deep sensation

- Vibration - Crude touch

- Proprioception - Kinesthesia

Cortical sensation

- 2 point discrimination - graphesthesia (traced fig.)

- stereognosis - Barognosis (Recog. Of wt)

- tactile localization

Co-ordination and balance

Equilibrium and non – equilibrium tests

Non – equilibrium tests

o Finger to nose

o Finger to therapist finger

o Finger to finger

o Pronation / supination

o Rebound test

o Tapping

o Heel on chin

o Drawing a circle

Equilibrium tests

Standing in a normal

Standing – feet together

Standing on one foot

Standing, laterally flex the trunk to each side

Standing – eyes closed and open (Romberg sign)

Walking, placing the heel of one foot infront of toe of opposite foot (Tandem walking)

Walk and pivot

Walk in a circle

Stair climbing with and without handrails

Limb length measurement

- True

- Apparent

- Segmental

Posture

- in supine - in prone

- in sitting - in standing

Functional assessment

- dressing - feeding - toileting

- transfer - combing - brushing

Hand function – fine motor function

- tip to itp

- side to pad

- cylindrical

- Spherical

- hook

Bladder and bowel

- Uninhibited - Atonic

- Autonomous

Involuntary movement:

- Chorea - Athetosis - Tremor

- Hemiballismus - dystonia

Gait

- Stance and Swing phase

- step length - Stride length

- cadence - toe out angle

- Base of support - ROM

Investigations

1. X – ray 3. M.R.I

2. CT Scan 4. Lumbar puncture

5. Blood test

PROVISIONAL DIAGNOSIS

Management

• Problem list

• Aims

• Means

• Report

Prognosis