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GENERAL INFORMATION Pt's name: Age: Significance: Sex / gender: Significance: Address: Civil Status: Handedness: Significance: Occupation: Referring Unit: Referring MD: Rehab MD: Date of Admission: Date of Referral: Date of IE: Dx: Informant / Reliability:  Relationship / Good Reliability Height(optional): Weight (optional): SUBJECTIVE INFORMATION C/C (Chief Complaint) (verbatim / translated): Pt's Goal HPI (History of Present Illness): PMHx (past medical history):  (+)/(-) DM, HTN, CVD etc  if (+), stable?how long? & status o controlled/ poorly controlled or uncontrolled Personal / Social Hx:  Personality: Type A/B  Smoking Hx: o Pack years = no. of pack(s)/ day x no. of years smoking  Alcohol consumption (daily/ occasionally) Home/ Work / School Situation:  if LE involvement - living arrangement, environment barriers  if UE involvement - usual bimanual task Ancillary Procedure:  Date / Test Procedure / Result Present Medication/s:  Medication / Dosage / frequency / Indication OBJECTIVE FINDINGS A. Vital Signs (before, during & after treatment)  T: C  PR: bpm  RR: cpm bpm  BP: mmHg Findings: Significance: B. Ocular Inspection 1. Level of Ambulation  Bed-ridden  Bed-bound  Bed fast  W/C borne  Mother-borne  Ambulatory, specify assistive device 2. Level of Consciousness

 Stuporous - responds are elicited only in response to loud noise or painful stimulation  Comatose - appears to be sleep does not respond to painful stimulation 3. Body built  Ectomorph - thin body  Mesomorph - muscular or sturdy  Endomorph - heavy or fat body 4. (+) Obvious Physical Findings  Trophic skin changes  Deformities  Atrophy / Hypertrophy  Swelling  Ecchymosis  Discoloration  Scars  Wounds  Gait Deviation  Postural Deviation  Asymmetry 5. (-) Findings but indicative of disease / illness C. Palpation 1. Thermicity  Normothermic  Hypothermic  Hyperthermic 2. Tenderness (Grade & Location)  Grade 1 - pt c/o pain  Grade 2 - pain & winces  Grade 3 - pain & withdraws from palpation  Grade 4 - pt will not allow palpation 3. Edema  Pitting  Non-pitting 4. Shoulder Subluxation (Grade & Laterality) 5. Muscle Spasm / Guarding & Splinting D. Neurologic Evaluation 1. LOC  Ranchos Los Amigos Level of Cognitive Function (RLALCF)  Glasgow Coma Scale (Adult & Children)  Glasgow Outcome Scale  Glasgow Leige Scale  GCS + Brainstem Reflexes  Galvestron Orientation Amnesia Test (GOAT)  Rappaport D/A Scale - Alternate to GOS 2. Sensory Testing STD used: cotton for light touch, pinprick for pain & thumb for pressure: Pt. has _% intact / sensory deficit as to LT / Pa/ Pr Significance: a. Superficial Somatic  Touch - use camel brush, piece of cotton or tissue  Superficial Pain - reshaped paper clip applied on dermatomes  Temperature - use 2 test tube w/ stoppers, one is filled w/ warm water & other w/ crushed ice b. Deep Somatic  Kinesthesia - Movement sense; ask the pt to indicate verbally the direction of the mov't while extremity is at motion. Findings: Significance:  Proprioception - Position sense; the joint is moved

 Alert - can carry normal conversation, w/ no delays & is aware of time / place / identity or identity, difficulty following commands  Obtunded - appears drowsy & lethargic but readily replies to verbal stimulation if questions are simple  Vibration - use tuning fork that vibrates at 128 Hz, ask the pt. to respond by verbally identifying the stimulus as vibrating or non-vibrating. Findings:

through ROM & held in static position & ask the pt. to describe the position verbally or duplicate the position of the extremity w/ the CL extremity. Findings: Significance: Significance: c. Discriminative  2-point Discrimination - two tips of instrument (reshaped paper clip) applied to the skin

simultaneously w/ each successive application, the tips are gradually brought closer until the stimulus is perceived as one Findings: Significance:  Cutaneous Tactile Localization - using fingertip, touch different skin surfaces, after each application of stimulus the pt. is given time to respond by identifying the location of the stimuli by pointing the area or by verbal description.

b. Superficial Cutaneous Reflex  Abdominal o Upper (T7-T9) o Lower (T11-T12)  Cremasteric (T12-L1)  Bulbocavernosus (S2-S4)  Clitocavernosus (S2-S4)  Superficial Anal (S2- S4) Findings: Significance: c. Primitive Reflex  Refer to developmental reflexes Findings: Significance:

Findings: Significance:  Graphesthesia - letters, numbers or shaped are traced on pt's palm, then asked pt to identify the figure drawn in the palm. Findings: Significance:  Stereognosis - pt. is given small object w/ different size & shape the asked to name the object verbally Findings: Significance: 3. Reflex Testing a. Muscle Stretch / Deep tendon Reflex Reflex Site of Normal Stimulus Response Jaw Mandible Mouth closes Biceps Brachioradialis

Triceps

Patella Medial Hamstring Lateral Hamstring Achilles

Biceps Tendon Brachiorad. tendon

Distal to tricep tendon just above olecranon process Patellar tendon Semimem. tendon Biceps Femoris tendon Achilles tendon

Grading: 0 -absent 1 - diminished 2 - average 3 - exaggerated 4 - clonus, very brisk 0 - areflexia + - hyporeflexia ++ - normoreflexia

Biceps Contraction Flexion of the elbow and / or pronation of the FA Elbow extension / muscle contraction

d. Pathologic Reflex Pathologic Reflex Stimulus Babinski Stroking of lateral aspect of sole of foot

Chaddock's

Oppenheim Gordon's Hoffman's (digital)

CNS Segment Cranial Nerve V C5-C6 C5-C6

Rossolimo's

Schaeffer's C7-C8

Clonus

Leg Extension

L3-L4

Knee flexion / muscle contraction Knee flexion / muscle contraction Plantarflexion of the foot

L5-S1

L5-S1 S1-S2

Lateral side of foot beneath lateral malleolus Anteromedial tibial surface Squeezing of calf muscles firmly "flicking" of terminal phalanx of index, middle, or ring finger

Tapping of the plantar surface of toes Pinching of Achilles tendon in middle third Dorsiflexion of the foot

Response -Extension of big toe and fanning of four small toes -Normal reaction on NB

Babinski like responses

Reflex flexion of distal phalanx of thumb and of distal phalanx of index or middle finger (whichever one was not "flicked") Plantar flexion of toe Flexion of foot and toes

Cyclical, spasmodic alternation of mm contraction & relaxation

Other Pathologic Reflexes:  Gonda  Bing  Stransky  Marie foix / Bechterev Findings: Significance: e. Developmental Reflexes  Refer to REFLEX DEVELOPMENT Findings: Significance: f. Associated Reactions  Homolateral Limb Synkinesis - occurs in hemiplegic limbs; Flexion of arm may elicit flexion of leg on the hemiplegic side or vice versa  Soque's Phenomenon - elevation of hemiplegic arm

+++ - hyperreflexia ++++ - clonus

above horizontal may elicit an EXT & ABD response of finger

Significance: Areflexia / Hypo / Hyper 2 to UMNL / LMNL  Raimeste's Phenomenon - ABD & ADD of normal limb produces similar response in the affected limb. Findings: Significance:

4. Motor Control  Muscle Strength  Tone Assessment

 Balance & Coordination Findings: Significance: a. Tone Assessment  Hypotonic  Flaccidity  Normotonic  Hypertonic  Spasticity  Decebrate & decorticate rigidity  Cogwheel & Leadpipe rigidity  Opistotonus Findings: Significance: Modified Ashworth Spasticity Scale  Grade 0 - no increase...  Grade 1 - slight increase...catch & release @ end ROM  Grade 1+ - slight increase...catch & release < 1/2 of ROM  Grade 2 - more marked inc...throughout most ROM  Grade 3 - passive mov't difficult  Grade 4 - affected rigid b. Balance  Static - focused on the maintenance of posture o double limb stance o single limb stance o Tandem stance o Romberg's Test Findings: Significance:  Dynamic - balance during weight shifting or mov't o Standing o Walking o Stopping o Turning o Starting Findings: Significance: Functional balance Grading Normal: o S - able to maintain steady balance without support o D - accept maximal challenge & can weight shift in all direction Good: o S - able to maintain balance w/o support o D - accept moderate challenge ; able to maintain balance when picking object on the floor Fair:

o o

S - able to maintain balance with handhold D - accept moderate challenge; able to maintain balance while turning head / trunk

Poor:

o o

S - requires handhold & assistance D - unable to accept challenge or moves w/ loss of balance

Outcome Measure for Balance o Berg Balance Scale (BBS) o Time Up & Go Test (TUG) o Functional Reach Test (FRT) o Multidirectional Reach Test (MDRT) o Performance Oriented Mobility Assessment (POMA)

o o

6 Minute Walk Test (6MWT) Dynamic Gait Index (DGI)

c. Coordination  Gross o involves ax of body posture, balance & extremity using large mm group (e.g crawling, kneeling, standing, walking & running)  Fine o concerned with the use of small mm group (manipulating objects in the hand o Power & precision grip  Equilibrium & Non-equilibrium Test Equilibrium Test  Standing in normal, comfortable posture  Standing w/ feet together narrow BOS  One leg stance  Displace balance unexpectedly  Rombergs test  Walking along the straight line  Marching in place  Stop & start abrupt while walking  Walk on heel & toes  Step over or around obtacle

Non -EquilibriumTest  Finger to nose  Finger to PT's hand  Finger to finger  Alternate nose to finger  Finger opposition  Alternate pronation/supination  Heel to shin  Drawing a circle on foot

5. Cranial Nerve Testing Nerve Function I Olfactory Smell II Optic

III Oculomotor

IV Trochlear

Vision

Pupillary reflexes / shape Elevates eyelid Turns eye up, down & in Constrict pupil Accomodates lens Turns abducted eye down Intorsion of eye Sensory: Face Cornea

V Trigeminal

Motor: Mastication

Assessment Assess sense of smell common odorants Assess visual Acuity: Central: Snellen eye chart Peripheral: vision, visual fields Test corneal light reflex Assess papillary size Assess position of eyelid Test pursuit eye mov't Test papillary light reflex Test accomodation reflex Test pursuit eye movt

Test sensation: forehead , cheeks, chin Test corneal reflex

Have patient clench jaws, hold against resistance

Turns eye out VI Abducent

Turns eye out

VII Facial

Sensory: Tearing: Lacrimal gland Salivary secretion: -submandibular -sublingual glands Taste from anterior tongue Motor: Facial expression

Equilibrium VIII Vestibulocochlear

IX Glossopharyngeal

X Vagus

Hearing

Taste: posterior third of tongue Somatosensations: - Posterior tongue - Oropharynx Deglutition, phonation Cardiac Depressor Bronchoconstrictor GI tract peristalsis, secretion Taste

Test pursuit eye movt

S/Sx of Damage Anosmia- inability to detect smells Blindness; impaired vision

Absence of light reflexes on shining light in eye Ptosis (drooping) eye deviates down and out Diplopia with attempted lateral gaze to contralateral side Lost of light and accomodation reflexes (ipsilateral eye) Diplopia with attempted downward / adducted gaze Adductor paralysis (ipsilateral eye) Loss of facial sensations, numbness Loss of corneal reflex ipsilaterally (blinking in response to corneal touch) Weakness, wasting muscles of mastication Deviation of jaw when opened to ipsilateral side Diplopia with attempted lateral gaze to ipsilateral side Diplopia with attempted lateral gaze to ipsilateral side Convergent strabismus Abductor paralysis - ipsilateral eye Loss of lacrimation; pain with blinking Decreased salivation - dry mouth

Test taste - sweet, salty, sour, bitter

Lost of taste (aguesia) anterior two-thirds of tongue

Assess motor function: - Raise eyebrows - Shows teeth - Smile - Close eyes tightly - Puff cheeks Assess balance Eye-head coordination (VOR) Assess for nystagmus Assess for auditory acuity Weber test: conduction Rinne test: sensorineural Assess taste: sweet, salty, sour, bitter

Paralysis ipsilateral facial muscles - inability to close eye - drooping corner of mouth - difficulty with speech articulation

Test gag reflex

Anesthesia of pharynx and larynx Dysphonia

Assess phonation, articulation Observe movt soft palate Swallowing

Dysphagia Dysphonia, hoarseness Palatal paralysis Cardiac dysrythmia, respiratory disturbances (bilateral vagal dysfunction)

Vertigo , dysequilibrium, nystagmus Gage instability with head rotations Deafness, impaired hearing, tinnitus

Loss of taste posterior third of tongue...