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Patient Assessment - Page 1 (Edit)
Date *
Patient Name *
PR No
Age / Gender *
F
M
T
Contact No
Reference
Address
Sasi Nagar
Occupation Type *
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Government
Non-Government
Senior Citizen
Others
Designation
Nature of Work
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Active
Desktop
Field
Travel
House Holder
others
Vitals
HEIGHT
WEIGHT
BP
PR
TEMP
SPO2
Other Health Issues & Treatment History
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History of Present Complaints
2+ months, Diabetic neuropathy Admitted in MMHRC due to indigestion for 10days - sudden onset after an indigestion problem for 10days 1+ year Right shoulder pain - Sudden onset after a fall from two wheeler ride
Onset
Sudden
Insidious
Gradual
Treatment Taken
NCS Analysis - Abnormal record to consider upper limb predominant motor axonol neuropathy with bilateral peroneal neurpopathy
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
Dr Karthiga, PT - Walking / Electrical stimulation to Peroneal muscles bilaterally No exercises given
Update
Present Complaints
Over all muscular strength reduced Bilateral lower limb weakness - Difficulty in getting up - walking and all Shoulder pain - Wakeup pain During ADL activities Feeling energy drained
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
19-20
Pain Scale
Worst
Same
Better
VAS
At Worst
At Best
Pain Type
Nociceptive
Neuropathic
Nociplastic
Skin Colour
Scar
Adherent
Non-Adherent
No Scar
Swelling
Soft Fluctuating
Leathery
Tough
Dry
Tened
Hard
Boggy
Spongy
Thick
8 to 24 Hours of Injury
Tenderness
Grade I
Grade II
Grade III
Grade IV
Remarks
MRI : FRACTURE OF RIGHT SCAPULA involving body with displacement of bony fragments and adjacent soft tissue injusry . hairline fracture of posterolateral aspect of right side 7th t0 11th ribs seen . thinrim ofhemo/pnuemo effusion noted
Update
Edit - Page 3
Dashboard
Patient Management
Edit - Page 3
ROM
AROM
Movement
Side
Part
Plane
Available Range
Pain Starts
Action
Select
Left
Right
Select
Neck
Wrist
Shoulder
Elbow
Spine
Hip
Knee
Ankle
Select
Sagittal
Frontal
Transverse
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PROM
Movement
Side
Part
Plane
Available Range
Pain Starts
Action
Select
Left
Right
Select
Neck
Wrist
Shoulder
Elbow
Spine
Hip
Knee
Ankle
Select
Sagittal
Frontal
Transverse
-
+ Add PROM
End Feel
Soft
Firm
Hard
Empty
MMT
-
+ Add MMT
Special Tests
Special Test 1
Special Test 2
Remarks
Patient had an Right shoulder injury 2yrs back - Difficulty in AROM Bilateral high stepping gait - Weakness of Peroneal compartment and dorsi flexors Patient needs counselling during the treatment sessions
Diagnosis
Patient Goals & Concerns
Physiotherapy Goals
Short Term Goals
Long Term Goals
Action
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Further Referral (if needed)
Physiotherapist Details
Assessed Physio Name
IAP Membership No.
Treatment In-Charge Name
IAP Membership No.
Update
Electrotherapy
Modality
Site
Details
Date
Remarks
Action
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Supportive Techniques
Technique
Details
Date
Remarks
Action
Shoulder mobilization - End range elevation - Hand behind back and neck
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Corrective Exercises
S.No
Exercise
Sets
Reps
Time
Date
Remarks
Action
1
-
2
-
3
-
4
-
+ Add Row
Date
Remarks
Weekly 3days Use FMS for activation Use Leg extension / curl machine Improve proximal muscle strength (LPHC)
Update
