PATIENT’S INFORMATION

I.History Taking

Date: Time:

Name: Age Sex (M)

(F)

Address: Refering Physician:

Marital status: Single ( ) Married ( )

Separated ( ) Widow ( )

Religion: Birth Date:

mm / dd / yy

Occupation: Nationality: Race:

BP: RR: Temp:

HR: PR: LMP:

Ht: Wt: BMI:

Handedness

R ( ) L ( )

Educational Attainment Remarks:

Elementary ( ) HS ( )

Vocational ( ) College ( )

Masteral ( ) none ( )

Chief Complaint:

History of Present Illness:

Present Medical Conditions:

Current Medications:

Allergies:

Past Medical History:

Previous Hospitalizations:

Surgeries:

Injuries, Accidents, Disabilities:

Family History:

Asthma ( ) MI ( ) Hreart Failure ( ) Kidney diseases ( ) CA ( )

Diabetes ( ) TB ( ) Hypertension ( ) Hemophilia ( )

Social History

Lifestyle

Daily Activities: _____________

Habits: _____________

Exercise: _____________

Diet: _____________

Household situation:_____________

Significant Relationships:_ ________

Remarks:

Sexual History

Active ( )

Birth Control ( )

Gender Preference (M) (F)

Remarks:

Substance Abuse

Alcohol ( )

Smoking ( )

Drug Usage ( )

Remarks: Remarks:

Employment Remarks:

Exposure to Carcinogens or

Environmental Agents

Remarks:

Systems Review

Skin

Rashes ( ) Bruising ( ) Lumps ( )

Dryness( ) Itchiness ( ) Sores ( )

Skin Discolorations ( )

Remarks:

Head

Headaches ( ) Dizziness ( )

Tenderness ( ) Lumps/Masses ( )

History of: Seizure ( ) Head Trauma ( )

Remarks:

Eyes

Visual Changes ( ) Diplopia ( )

Inflammation ( ) Redness ( )

Discoloration ( ) Blurring of Vision ( )

Wear Glasses/contact Lenses ( )

Remarks:

Ears Remarks:

Tinnitus ( ) Vertigo ( ) Pain ( )

Discharge ( ) Hearing Aids ( )

Change in Hearing sensation ( ) Nose

Nose Bleeds ( ) Discharge ( ) Sinus Disease ( ) Change in sense of smell ( )

Remarks:

Mouth and Throat

Hoarseness ( ) Dental Diseases ( )

Sore Throat ( ) Pain ( )

Sore tongue ( ) Bleeding Gums ( )

Dry Mouth ( ) Odor ( )

Remarks:

Neck

Lumps ( ) Pain ( ) Stiffness ( )

Remarks:

Respiratory

Cough ( )

Shortness Of Breath ( )

Hemoptysis ( )

Dyspnea ( )

Sputum ( )

Color ______ Amount ________

PTB Hx: ( )

Tx (Y) (N) year_______

Vaccination for Influenza or Pneumococcus ( )

Remarks:

Cardiovascular

Chest Pain ( ) Orthopnea ( )

Extremity Edema ( ) Claudication ( )

Dtspnea on Exertion ( )

Remarks:

Gastrointestinal

Dysphagia ( ) Vomiting ( )

Remarks:

Diarrhea ( ) Constipation ( )

Jaundice ( ) Hemorroids ( )

Bloody Stool ( ) Melena ( ) Hematamesis ( )

Abdominal Pain ( )

Pain with Defecation ( )

Excessive Passing of Gas ( ) Urinary

Frequency ____________

Dysuria ( ) Polyuria ( )

Hematouria ( ) Discharge ( )

Pain on Urination ( ) Hesitancy ( )

Remarks:

Genital

MALE

Sexually Transmitted Infection ( ) __________

Testicular Pain ( )

Testicular Mass ( )

Hernias ( )

Penile Discharge ( )

Sores ( )

Itching ( )

Vasectomy ( )

Drive ____________

FEMALEAge of Menarche ______________

LMP ______________

Intervals ________/month

Frequency ________ days

Duration of Periods __________days

Dysmenorrhoea ( )

Premenstrual Tension ( )

Bleeding b/w Intercourse ( )

Itching ( ) Sores ( ) Lumps ( )

Last Pelvic Exam ____________

Last Pap Smear ____________

Menopause ( ) Post Menopausal Bleeding ( )

Vaginal Discharge ( )

Sexually Transmitted Infection ( ) __________

Tx (Y) (N)

Endocrine

Polyuria ( ) Polydypsia ( )

Polyphagia ( ) Skin/ Hair Changes ( )

Hormonal therapy ( )

Cold/ Heat Intollerance ( )

Remarks:

Musculoskeletal

Joint Pain / Swelling ( ) Cramps ( )

Arthritis ( ) Twitching ( )

Stiffness ( ) Back/ Muscle Pain ( )

Able to do ROM (Y) (N)

Remarks:

Lymph Nodes

Cervical ( ) Auxillary ( )

Supraclavicular ( ) Inguinal Nodes ( )

Remarks:

Psychological

Depression ( ) Anxiety ( )

Adverse Attitudes ( ) Mood swings ( )

Mental Problems ( )

Remarks:

General:

Weight gain ( ) loss ( )

Appetite gain ( ) loss ( )

Chills ( ) Fatigue ( ) Fever ( )

Night Sweats ( ) Weakness ( )

Memory Loss ( ) Confusion ( )

REMARKS:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II. Inspection(Somatic Motor)

A. How the patient sits, stands, walks and gestures.

Posture (Standing)

Tremors ( ) Left ( )Right

Remarks________________________________________________________________

_______________________________________________________________________

Posture (Sitting)

Tremors ( ) Left ( )Right

Remarks________________________________________________________________

_______________________________________________________________________

Gen. Activity Level

Tremors ( ) Left ( ) Right

Remarks________________________________________________________________

_______________________________________________________________________

STATION AND GAIT TESTING

How the patient walk:_________________________________________________________

On toes:________________________________________________________________

On heels:______________________________________________________________

On tandem:_____________________________________________________________

B. Palpation (Somatotype or Body Build)

Upper Extremities Left Right

( ) body asymmetry ( ) body asymmetry

( ) atrophy ( ) atrophy

( ) hypertrophy ( ) hypertrophy

Lower Extremities Left Right

( ) body asymmetry ( ) body asymmetry

( ) atrophy ( ) atrophy

( ) hypertrophy ( ) hypertrophy

C.Muscle Tone

Spaticity ( ) Left ( ) Right

Clonus ( ) Left ( ) Right

Flaccid ( ) Left ( ) Right

Rigidity ( ) Left ( ) Right

Remarks_______________________________________________________________________

III. Test for Muscular Weakness

A. Range of Motion (ROM)Test for ROM by letting patient elevate his/her arms sideways, upfront and above his/her head.

Remarks: ____________________________________________________________________

B. Neck Muscles1. Flexor

Let Pt flex his chin to chest slightly. Ex places one palm on forehead of the Pt and the other at the back. Instruct Pt to flex neck while Ex resists force.

Muscle Strength:

5 4 3 2 1 0

Remarks:

2. ExtensorEx places one palm on occiput of Pt. and the other on the chest of Pt. Instruct Pt to extend neck backwards while Ex resists force.

Muscle Strength:

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

C. Shoulder Muscles and shoulder girdle1. Arm Elevation

Request patient to hold the arms straight out to the sides. Press down on both arms at a point where you expect your strength to approximate the patient’s Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

2. Arm Adduction downwardRequest Pt to extend his/her arms to the sides and resist your force to elevate them.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

3. Arm adduction across the chest (pectoralis muscle)Request Pt to extend his/her arms in front and cross his wrists. Make patient resist while you pull them apart.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

4. Scapular adductionWith the hands on the hips, the patient forces the elbows backward as hard as possible. The Ex tries to push them forward while behind the Pt.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

5. Scapular wingingRequest Pt to lean forward against a wall, supporting the body with outstretched arms.

Winging:

Remarks:

______________________________________________________________________

D. Upper Arm Muscles1. Elbow Flexor

Pt tightly flexes forearm. Ex braces one hand against Pt’s shoulder and the other hand grasping the Pt’s wrist attempting to straighten the Pt’s forearm.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

2. Elbow extensorRequest Pt to extend forearm while biceps are in the flexed position. Ex resists the force.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

E. Forearm Muscles1. Wrist Flexor

The Pt makes a fist and holds the wrist flexed against Ex’s efforts to extend it.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

2. Wrist ExtensorRequest pt. to make a fist then place it on top of a flat surface for support. Pt extends wrist (dorsiflex) while resisting Ex’s force to flex it down.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

F. Finger Muscles1. Abduction- Adduction of the fingers

Request pt to Adduct and Abduct Pt’s fingers against Ex’s fingers.

Remarks:

___________________________________________________________________________

2. Finger ExtensionRequest Pt. to hold out arms palms down and fingers extended. Ex turns his/her arms over so the fingernails presses against the dorsum of the Pt’s.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

3. Finger FlexionRequest Pt to squeeze Ex’s two fingers. Ex then tries to pull fingers out of Pt’s grip while Pt resists it.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

G. Abdominal MuscleRequest Pt to lie down in a supine position. Ask the patient to do a sit-up. Observe the umbilicus.

Umbilicus position:

Center Upward Downward Left Right

Remarks:

______________________________________________________________________________

H. Large Back MusclesRequest Pt to lie in prone position while arching his/her back

Remarks:

______________________________________________________________________________

I. Hip girdle1. Hip flexion

Request Pt to lift a knee off of the table surface and to hold the thigh in a flexed position. Ex tries to push knee back down using his/her palm

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

2. Hip ExtensionPt extends thighs backwards while Ex tries to flex it.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

3. Thigh abduction and adductionWith Pt sitting, request Pt to hold the legs abducted while Ex tries to adduct them. Then Ex asks Pt to hold the legs adducted while Ex tries to abduct them.

Muscle Strength:

ADDUCTIONRight Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

ABDUCTIONRight Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

J. Thigh Muscles1. Knee extensor

Have the Pt extend knee towards buttocks while Ex opposes it

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

2. Knee FlexorPt holds the knee at angle of 90 degrees while Ex tries to straighten it by grasping the Pt’s ankle.

Muscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

K. Ankle and Toe movementsHave the Ptdorsiflex, invert and evert the feet

DORSIFLEXIONMuscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

INVERSIONMuscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

EVERSIONMuscle Strength:

Right Side

5 4 3 2 1 0

Left Side

5 4 3 2 1 0

Remarks:

___________________________________________________________________________

IV.Muscle Stretch Reflex(Deep)

Jaw reflex

With the patient’s jaw sagging loosely open, the examiner rests a finger across the tip and strikes it a crisp blow

Biceps reflex

The examiner’s thumb places slight tension on the patient’s biseps tendon, the lacetusfibrosus. The examiner strikes his thumbnail a crisp blow

Triceps Reflex

A) Dangle the patient’s forearm over your hand and strike the triceps tendonB) Cradle the patients forearm in your hand and strike the triceps tendon

Brachioradialis Reflex

Cradle the patient’s forearm in one hand, placing the thumb on the radius. The hammer strikes the examiner’s thumbnail rather than the patient’s radius. Don’t whack away on the patient’s unprotected bone. the

Finger Flexion (Tromner’s method)

The examiner supports the patient’s completely relaxed hand and briskly flips the patient’s distal phalanx upward, as though to flip a handful of water high into the air. The patient’s fingers and thumb flex and response to the stretch of the finger flexor muscles.

Finger Flexion (Hoffman’s method)

The examiner depresses the distal phalanx and allows it to flip up. The extensor of the phalanx stretches the flexor muscles, causing the fingers and thumb to flex. This method is only effective with very brisk muscle stretch reflexes.

Quadriceps Femoris Reflex

A) With the patient sitting:The examiner strikes the patellar tendon a crisp blow. By placing a hand on the patient’s knee, the examiner feels and sees the magnitude of the response

B) With the patient supine:

The examiner bends the patient’s leg to place slight tension in the patellar tendon. The blow then will deform the tendon and transmit a stretch to the muscle

Triceps Surae Reflex

A) With the pt. sitting:With relaxed leg, the examiner dorsiflexes the foot to place slight tension on the triceps surae muscle. Try reinforcement if no reflex occurs

B) With the pt. supine:With the knees bent and relaxed, the examiner dorsiflexes the patient’s foot to place a slight tension on the triceps surae muscle. Try reinforcement if no reflex occurs

Toe flexion Reflex (Rossolimo’s sign)

Identical with the finger flexion method. Tapping the ball of the foot elicits toe flexio

Muscle stretch reflex GradeL R

Jaw ReflexBiceps ReflexTriceps ReflexBrachioradialis ReflexFinger Flexion (Tromner’s method)Finger Flexion (Hoffman’s method)Quadriceps Femoris ReflexTriceps Surae ReflexToe flexion Reflex (Rossolimo’s sign)

Grading of muscle stretch reflex

0 Areflexia1 Hyporeflexia2 Normal3 Hyperreflexia4 Clonus present

Inspection while at RestFlaccid / Floppy:Uncomfortable Joint Position:Rag Doll Posture:

Inspection while walkingFlaccid / Floppy:Arms fail to swing properly:Hypotonic Stretch reflexes / Pendulous:

Romberg’s test:

V.Skin and muscle (superficial) reflexes

Plantar Reflex

1. Position the patient in a supine position with the limbs relaxed and symmetrically arranged, with the knees straight or slightly flexed and turned.

2. Inform the patient that the procedure might be uncomfortable by saying: “I am going to press your foot gently. If it’s unpleasant, tell me”.

3. Hold the patient’s ankle with one hand to keep the foot in place and control the pressure of the plantar stroke.

4. Place the stimulus object (serrated, broken end of a tongue blade) at the patient’s heel stopping short at the base of the foot.

5. Begin with a very slight pressure or even apply the stroke at the lateral aspect of the foot, (Chaddock’sManeuver) a region less sensitive than the sole.

6. Stroke it slowly along the lateral margin of the foot.

7. If no response or inconstant responses occur the stimulus is probably wrong. Try again and consider the following:

A. Length: Increase length by swinging the stroke across the ball of the foot

B. Velocity

C. Pressure: Increase the pressure but remain short of pain and within the patient’s

Limit of Tolerance

RESULT Eponym Maneuver

extensionflexion

Babinski (Plantar toe reflex)

Move an object along the lateral aspect of the sole.

Chaddock’s Maneuver

Move an object along the lateral side of the foot.

Schaeffer (Achilles-toe reflex)

Squeeze hard on the Achilles tendon.

Oppenheim (Shin-toe reflex)

Press your knuckles on the patient’s shin and move them down.

Gordon (Calf-toe reflex)

Squeeze the calf muscles momentarily.

Bing (Pinprick-toe reflex)

Make multiple light pinpricks on the dorsolateral surface of the

foot.Gonda, Stransky (Toe-pull reflex)

Pull the fourth toe outward and downward for a brief time and release suddenly.

Normal Variations

A. Flexion synergy- some normal person will shoe little or no movement after plantar stimulus and this is called “ mute Sole”. palpate the extensor hallucislongus tendon, if mechanical factors prevent the movement

B. Triple flexion synergy- the withdrawal movement like: 1. Dorsiflexion of the ankle 2. Flexion of the knee 3. Flexion of the knee. These are normal response of a person like stepping on a sharp object.

C. Small toes may fan but it is not a clinically important part of the plantar reflex

VI. Cerebellar Examination

I. Initial Observation

Remarks:_________________________________________________________

A. SPEECH (√/X)

Ask patient to state his/her name/address/birthday etc.

Slurred: ( ) Fluent: ( ) Mute: ( )

Remarks:_________________________________________________________

B. EYE MOVEMENT (√/X)

1.) Ask Pt to look straight ahead and place your fingers in the temporal fields.

2.)AskPt to look first at one finger and then the other and then direct the Pt to

look rapidly from one to the other several times

Dysmetria of saccades: ( ) R: ( ) L: ( )

Jerky rather than smooth: ( ) R: ( ) L: ( )

Slowness in initiating movement: ( ) R: ( ) L: ( )

Skew movement: ( ) R: ( ) L: ( )

Remarks:_________________________________________________________

C.STANCE and GAIT(√/X)

1.) Ask Pt to stand with feet together

2.)AskPt to walk towards a straight line

3.)Tandem Walking (ask Pt to walk on a straight line,placing heel to one foot directly in front of the toe of the other)

Swaying when standing: ( ) Broad-based stance: ( ) Broad-based Gait: ( )

Remarks:__________________________________________________________

D. ARMS (√/X)

1. Finger-to-nose test & Decomposition of movement

a.) Ask Pt to extend arms straight out in front

Wavering of arms: ( ) R: ( ) L: ( )

Rhythmic postural tremor: ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

b.) Ask Pt to be in bat wing's position (hold finger apart in front of the nose, with arms elevated horizontally)

Wavering of arms: ( ) R: ( ) L: ( )

Rhythmic postural tremor: ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

c.) Ask the Pt to hold arms straight out and then instruct to place index finger on the tip of his/her nose.

Dystaxia increases as finger approaches

nose (intention type of kinetic tremor): ( ) R: ( ) L: ( )

Pt fails to precisely place tip of finger to

tip of nose (dysmetria) ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

d.) Movement 1:

Ask Pt to move arm from side to level of nose

Unsuccessful ( ) R: ( ) L: ( )

Long inefficient trajectory ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

e.) Movement 2:

Ask Pt to bring fingertip to nose

Unsuccessful ( ) R: ( ) L: ( )

Long inefficient trajectory ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

f.) Ask Pt to alternately touch his/her nose, Ex’s finger, then back to his/her nose several times

(Dystaxia) increases as finger approaches

nose (intention type of kinetic tremor): ( ) R: ( ) L: ( )

Pt fails to precisely place tip of finger to

tip of nose (dysmetria) ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

2. Thigh-Patting Test (for Dysdiadochokinesia)

a.) Demonstrate by lightly slapping own thigh, alternating first by slapping the palm and then the back of the hand,as rapidly and rhythmically as possible.

Overshooting: ( ) R: ( ) L: ( )

Undershooting : ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

b.) Make an audible sound with each pat.

Slower than normal sound rhythm: ( ) R: ( ) L: ( )

c.) Ask Pt to make actions that sound exactly like

d.) Test hands separately and together

Slower than normal sound rhythm: ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

3. Finger tapping test

a.) Place audiocassette on table and ask Pt to grasp it between thumb and third digit, leaving index finger free to tap.

Difficulty assuming position or even in

picking up and arranging box: ( ) R: ( ) L: ( )

b.) Ask Pt to tap as rapidly as possible for

10 seconds. (Normal subjects tap at rate ( ) R: ( ) L: ( )

of 50 taps per 10 seconds)

Remarks:__________________________________________________________

4. Wrist-tapping test

a.) Ask patient to stand with eyes closed

and arms outstretched ( ) R: ( ) L: ( )

b.) Ex strikes back of pt’s wrist to displace

arm ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

5. Arm-pulling test

a.) Ask patient flex R arm

Overshooting forward and backward ( ) R: ( ) L: ( )

b.) Ex’s L hand pulls Pt’s arm while R

hand positions at Pt’s R shoulder for

Face protection

Overshooting forward and backward ( ) R: ( ) L: ( )

c.) Ex suddenly release Pt’s arm

Overshooting forward and backward ( ) R: ( ) L: ( )

d.) Ex does the same procedure for L arm

Overshooting forward and backward ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

E. LEGS (√/X)

1. Heel-to-shin Test

a.) While Pt is supine or sitting, ask him/her to place one heel precisely on opposite knee

Positional tremor while heel is at knee ( ) R: ( ) L: ( )

b.) Ask Pt to hold heel to knee for few seconds

Accuracy of heel placement and movement ( ) R: ( ) L: ( )

while at knee

c.) Ask Pt to run the heel straightly down the shin

Accuracy of heel placement and movement ( ) R: ( ) L: ( )

while at the shin

Remarks:__________________________________________________________

2. Heel-tapping test

a.) While Pt is supine or sitting, ask him/her to place one heel over the other shin with heel as rapidly as possible on one spot

Misses spot (dysmetria) ( ) R: ( ) L: ( )

Tpsdysrhythmically (dysdiadochokinesia) ( ) R: ( ) L: ( )

Remarks:__________________________________________________________

3. Inspection of Hypotonia and Quadriceps Femoris Reflex

a.) Ask patient to sit and rest

Assumes floppy postures and joint positions ( ):__________

(rag-doll or dumped-in-a-heap postures):

b.) Ask Pt to walk

Presents a floppy, sagging, loose-jointed appearance : ( ) :__________

Arms fail to swing properly ( ) R: ( ) L: ( )

Knees bend backward slightly (genu recurvatum) ( ) R: ( ) L: ( )

Head and trunk bob—a rag-doll gait ( ) R: ( ) L: ( )

(like in drunkenness)

Remarks:__________________________________________________________

c.) Ask Pt to sit with legs swinging freely over table edge.

Leg swings to and fro several times like pendulum ( ) R: ( ) L: ( )

d.) Ex elicits Quadriceps Muscle Stretch Reflex

Leg swings to and fro several times like pendulum ( ) R: ( ) L: ( )

Remarks:______________________________________________________

That in all things God may be Glorified!

ORA ET LABORA

Regalado, Jocos Louise

Reyes, DanicaDanielle

Reyes, Jordan Gabriel Angelo

Reyes, Kenneth

Rivera, Al Enrico

Rivera, Diandra Marie