INITIAL EVALUATION

(November 9, 2018)

Name: D. A.
Age: 35 y.o.
Sex: M
Address: Cabatuan, Iloilo
Nationality: Filipino
Civil status: Married
Occupation: Seafarer
Handedness: (L) handed
Religion: Roman Catholic
Date of Referral: August, 2018 c exact day unrecalled
Referring MD:
Physiatrist: Dr. Gicos
Medication:
Informant’s Reliability: pt. is 100%
Diagnosis: crushing injury ® hand, chip fx base of distal phalanx, digit 3 ® hand, S/P ORIF, S/P
amputation of e middle phalanx of the 4th and 5th digit

/S/:
C/C: pt. c/o difficulty in gripping c a P/S of
HPI:
When:
Where:
How: (LOC); wkness; slurring: BP ;meds; PS; activities; remedies

Whom:
Where (hosp):
Who (physician present)
What (ancillary):

Surgery: who;how long in icu; reg room; when d/c; PTR

Past Medical Hx:

Condition Date Hospital

Family Medical Hx:

Condition Maternal Paternal Patient
HTN
DM
RA/OA
ASTHMA
HEART DSE

Functional Hx:
Patient’s Profile:
Personal Hx:
Psychological/Psychiatric Hx:
Lifestyle:
Diet:
( ) milk drinker
( ) coffee drinker
( ) soda drinker
( ) alcoholic beverage drinker
( ) smoker
Social Hx:
Family:
Home Situation: Gate to MD
MD to LV
LV to Kitchen:
LV to BR:
BR to CR:

Vocational Hx:
Work Hx:
Educational Attainment:
Finances:

Ancillary Procedures:

Procedure Taken (When & Where) Results

Medications:
Medication (mode as Dosage/Frequency Indication Side Effects
necessary)

Pt’s. Goal:

/O/:
OI:
Body type:
Amb:
Gait deviation:
Spasticity:
Attachments:
Swelling:
Atrophy:
Edema:
Wound:

V/S:

a tx During tx p tx
BP(mmHg)
PR(bpm)
RR(cpm)
T (˚C)
Sig:

Palpation: (may include diagrams)

Spasticity:
Atrophy:
Mm spasm:
Body temp:

Neurological Evaluation: (if pertinent)

Mental Status Examination:
Arousal:
Orientation:
Attention:
a. Selective Attention: (digit span test)
b. Sustained Attention:
c. Alternating Attention:
d. Divided Attention: (walki-talkie test)

Cognition:
a. Information and Vocabulary:
 Word Comprehension: (3pt command)
 Naming:
 Repetition: (no ifs ends or but)
 Reading: (phrase)
 Writing: (write something)
b. Fund of Knowledge (president):
c. Calculation Ability:
d. Proverb interpretation (nasa tao ang gawa, nasa diyos ang awa):
e. Constructional ability (copy figures):

Memory:
Long-term:
Short-term:
Sensory Examination:
Superficial:
Light Touch
Area Tested L R
 Pinprick
Area Tested L R

Deep:
Proprioception
Joint Tested L R

Kinesthesia
Joint Tested L R

Cortical:
L R
UE UE
Graphesthesia (shape)
Stereognosis (object)

Cranial Nerve Testing:

Cranial Nerve Test Findings

Tone Assessment: (refer to Sullivan)

Muscle groups Grade

Reflex Assessment:
DTR:
 Legend for Deep Tendon Reflexes
0 no response
+ hyporeflexia
++ normoreflexia
+++ hyperreflexia
++++ clonus

Superficial Cutaneous Reflex:

Primitive/Tonic Reflexes: (refer to Sullivan for grading)
Pathological Reflexes: (For UMNL/ LMNL)
Reflexes Procedure Expected Response Result
Babinski stroking the lateral aspect of the sole dorsiflexion of the big toe with fanning
of the foot from the heel to the ball out or abduction of the small toes
and across the forefoot
Clonus sudden dorsiflexion of the foot sustained jerking of the foot

Babinski-Like Responses
Chaddock’s Toe Sign stroke the lateral malleolus dorsiflexion of the big toe with fanning
out or abduction of the small toes
Gordon’s Leg Sign squeeze the calf area dorsiflexion of the big toe with fanning
out or abduction of the small toes
Oppenheim’s Sign firm downward stroking of the dorsiflexion of the big toe with fanning
tibia and tibialis anterior out or abduction of the small toes
muscle is done
Gonda Reflex press one the other toes dorsiflexion of the big toe with fanning
downward and releases it out or abduction of the small toes
with a snap
Schaeffer’s Sign squeeze the Achilles tendon dorsiflexion of the big toe with fanning
out or abduction of the small toes
Stransky Reflex vigorous abduction of the little dorsiflexion of the big toe with fanning
toe for 1-2 seconds with out or abduction of the small toes
subsequent sudden release

Coordination and Balance Examination:

Part I: Nonequilibrium Coordination Tests
Key to Grading
4 Normal Performance
3 Minimal Impairment : Able to accomplish activity; slightly less than normal control, speed, and
steadiness
2 Moderate Impairment : Able to accomplish activity; movements are slow, awkward, and unsteady
1 Severe Impairment : Able only to initiate activity without completion; movements are slow with
significant unsteadiness, oscillations, and/or extraneous movements.
0 Activity Impossible
GRADE: COORDINATION TEST GRADE: COMMENTS
LEFT RIGHT
Finger – to – Nose
Finger – to – Therapist’s Finger
Finger – to – Finger
Drawing a Circle Hand
 Alternate nose – to – Finger
Finger Opposition
Mass Grasp
Pronation/Supination
Pointing and Past-Pointing
Fixation/Position Holding (UE)
Fixation/Position Holding (LE)
Heel- on- shin
Part II: Postural Control And Balance Tests
Key To Grading:
4 Normal: Able to maintain steady balance without handhold support (static). Accepts maximal
challenge
and can shift weight easily within full range in all direction (dynamic)
3 Good : Able to maintain balance without handhold support, limited postural sway (static). Accepts
moderate challenge; able to maintain balance while picking object off floor (dynamic)
2 Fair : Able to maintain balance with handhold support; may require occasional minimal assistance
(static). Accepts minimal challenge; able to maintain balance while turning head/trunk
(dynamic).
1 Poor : Requires handhold support and moderate to maximal assistance to maintain position
(static).
Unable to accept challenge or move without loss of balance (dynamic).
0 Absent : Unable to maintain balance
GRADE BALANCE TEST COMMENTS
Sitting in a normal comfortable position
Sitting, weight shifting in all directions
Sitting, multidirectional functional reach
Standing in a normal comfortable posture
Standing, feet together (narrow base of support)
Standing, with one foot directly in front of the other (tandem
position)
Standing: eyes open (EO) to eyes closed (EC) (Romberg Test)
Standing in tandem position: EO to EC (Sharpened Romberg Test)
Standing, multidirectional functional reach
Walk: sideways
Walk: backwards
March in place
Stair climbing with handrail
Stair climbing without handrail
Stair climbing: one step at a time
Stair climbing: step-over-step
Reference: Physical Rehabilitation, 6th Edition: Susan B. O’Sullivan, Thomas J. Schmitz, and George
D. Fulk
Findings:
Significance:

Overall Neurological Assessment:

Musculoskeletal Assessment:
Anthropometric Assessment: (if pertinent)
MBT: Landmark:
Area Tested L R Difference

Sig:
LGM: Landmark:
Area Tested L R Difference

Sig:

LLD:
a. True
L R Difference

b. Apparent
L R Difference

c. Segmental
Area L R Difference

Sig:

ROM:
All major joints of the body are actively and passively assessed and found to be WNL, pain-free and c N
end-feel, Except:
Joint AROME PROM
Motion

Sig:

Accessory Joint Motions Assessment: (refer to Sullivan for grading)

Joint Motion Grade

Sig:

MMT/FMT:
All major mm groups of (B) UE, LE, and trunk are tested and grade 5/5,Except:
Muscle Groups Grade
R L

Grading:
0 – no palpable contraction
1 – palpable contraction
2+ - less than ½ the available ROM against gravity
3 – full available ROM against gravity
3+ - less than ½ the available ROM again gravity with moderate resistance
3- - greater than ½ the available ROM against gravity
4- - greater than ½ the available ROM against gravity and moderate resistance
4 – full available ROM against gravity and moderate resistance
5 – full available ROM against gravity and maximal resistance

Grip Strength:
L R Difference

Sig:

Special Tests:
Test Patient’s Response Results

Sig:

Postural Analysis:
ANT POST LAT
Head R earlobe is mm bulk of Earlobe is level
level with L erector spinae with acromion
is symmetric process
Shoulder R acromion is R acromion is Normal
level with L level with L
Hip/pelvis R and L ASIS R popliteal Toes in neutral
is level crest is level position
with L
Thigh mm bulk on B mm bulk on B mm bulk on B
thigh is equal thigh is equal thigh is equal
Knees R patella is R popliteal Knees in
level with L crest is level neutral position
with L
Leg mm bulk on B mm bulk on B mm bulk on B
leg is equal leg is equal leg is equal
feet R lateral Achilles tendon Normal medial
malleolus is is in neutral arch
level with L position
Sig:

Gait Analysis:
stance L R swing L R
HS ACC
FF MS
MS DEC
HO
TO

Sig:

Pulmonary Assessment: (if pertinent)

a. Breathing Pattern:
 Rest Activity
b. CRate:
o Regularity:
u Location of ventilation:
g
h:
c. Tracheal Deviation:
d. Chest wall Excursion:
Measurement Symmetry
e. F Angle of Louis
r Xiphoid process
e Between Siphoid process et
mumbilicus
i
tus
Apical

Anterior
Lateral
Posterior

f. Auscultation:
g. CV endurance: 6-MWT
Other tests:

Vestibular Assessment:
Integumentary Assessment:

BADL/IADL/Work/ Sport and Recreational Assessment: (Based on Magee)

Activity Performance (descriptive)
Bed mobility/ Transitional mobility
Moving in bed
a. Supine to
side lye
b. Side lye to
prone
c. Prone to
supine
Supine to Sitting up
Sitting up- standing
up
Hygiene activities
Bathing
Combing/ grooming
Brushing teeth
Eating activities
Using utensils
Managing glass and
cup
Dressing activities
Putting on clothes
Putting on socks
and shoes
Transfer activities
Bed to chair/ w/c
Toilet
Tub/ shower
Getting into car/
vehicle
Walking activities
Level Surfaces
Unlevel Surfaces
Sig:

/A/:
PT Impression:
Prognosis:
Problem list: (priorization)