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Patient Assessment - Page 1 (Edit)
Date *
Patient Name *
PR No
Age / Gender *
F
M
T
Contact No
Reference
Address
Gayathri Nagar 1st Street
Occupation Type *
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Government
Non-Government
Senior Citizen
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Designation
Nature of Work
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Active
Desktop
Field
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Vitals
HEIGHT
WEIGHT
BP
PR
TEMP
SPO2
Other Health Issues & Treatment History
-
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History of Present Complaints
3+ weeks - Right scapula - 6months back - Right shoulder pain - settled with Physiotherapy - Defined as Overuse injury by the Patient - Treatment taken with Dr Karthik, Anaiyur as Home visit - Patient informed that the shoulder pain is no connection with present scapula pain
Onset
Sudden
Insidious
Gradual
Treatment Taken
Nil for the present complaint
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
NA
Update
Present Complaints
Pain - Right medial border of scapula while bowling - settles with rest
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
35
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
Update
Edit - Page 3
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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
-
+ Add AROM
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 seems overeducated with his MSK problems - He had Right shoulder pain 6months back - Right ankle pain - Over weight too Patient is INTERNET DEPENDENDENT FOCUS: Counselling / Education - Correct scapula winging - Rotator cuff strength Planned for weight loss after scapula pain settled
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
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Corrective Exercises
S.No
Exercise
Sets
Reps
Time
Date
Remarks
Action
1
-
2
-
3
-
4
-
5
-
6
-
7
-
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Date
Remarks
8 sessions on alternate days followed by enroll him in weight loss program Treatment sessions Rs.800
Update