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Vital Sign
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vital sign comment
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Height
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Weight
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Temp
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Blood Pressure
/
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Pulse
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Chief Complaint
|
Chief Complaint?
• • •
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History Of Injury / Causation
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History of Injury
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Struck on the
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Date of Accident
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Looking
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Air bags deployed?
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What did patient strike in car
• • •
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Unconscious?
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Seatbelts?
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Immed. Pain
• • •
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Where did patient go?
• • •
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Additional Treatment
• • •
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Imaging and treatment?
• • •
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Getting better/worse
|
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Past Medical History
|
what's the PMH?
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ROS
|
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General Eye system [-]
|
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Musculoskeletal [-]
|
Musculoskeletal
• • •
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MSK Comments
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Neurological [-]
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Neurological
• • •
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Neuro Comments
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History of Present Complaint
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present complaint comment
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Quality
• • •
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Quality Comments
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Severity
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Severity Comments
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Modifying Factors
• • •
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Modifying Factors Comments
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Physical Examination
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Non-Spinal Palpation
• • •
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Spinal Palpation
• • •
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Spinal Palpation Comments
|
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Observation edema?
• • •
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Muscle Pain/Tenderness/Spasms
• • •
|
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Cervical ROM
• • •
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Thoracic ROM
• • •
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Lumbar ROM
• • •
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Spine Orthos
• • •
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Orthopedic Test
|
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Jackson Compression Test Left(+)
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Jackson Compression Test Right (+)
|
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Maximum Cervical Compression Test Left(+)
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Maximum Cervical Compression Test Right(+)
|
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Shoulder Depression Test Left(+)
|
Shoulder Depression Test Right(+)
|
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Forestier's Bowstring Sign on left (+)
|
Forestier's Bowstring Sign on right(+)
|
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Kemp's Test (+)Left
|
Kemp's Test (+)Right
|
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Straight Leg Raise Test (+) Left @60
|
Straight Leg Raise Test (+) Right @ 45
|
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Valsalva's Test
|
Straight Leg Raise Test (-) Left @60
|
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Cervical Distraction
|
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Extremities WNL
|
Extrem Comments
|
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Chest/Ribcage
|
Observation
• • •
|
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Tenderness
• • •
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No Pain
• • •
|
|
|
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Face
|
Observation
• • •
|
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Tenderness
• • •
|
|
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Left Eye
|
Observation
• • •
|
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Eyes Comments
|
|
|
|
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Abdomen
|
Observation
• • •
|
|
Tenderness
• • •
|
|
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Lt. Shoulder
|
Rt. Shoulder
|
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Bilateral shoulders
|
|
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Tenderness
• • •
|
Observation
• • •
|
|
Shoulder ROM
• • •
|
Shoulder Ortho
• • •
|
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Apley's Test (+) on right
|
Apley's Test (+) on left
|
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Dugas's Test (+) right
|
Dugas' Test (+) left
|
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Impingement Sign (+) right
|
Impingement Sign (+) left
|
|
|
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Lt. Upper arm
|
Rt. Upper Arm
|
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Tenderness
• • •
|
Observation
• • •
|
|
Muscle Pain/Tenderness/Spasms
• • •
|
|
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Lt. Elbow
|
Right Elbow
|
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Tenderness
• • •
|
Observation
• • •
|
|
Elbow ROM
• • •
|
Elbow Ortho
• • •
|
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Left Forearm
|
Right forearm
|
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Tenderness
• • •
|
Observation
• • •
|
|
No Pain
• • •
|
|
|
|
|
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Right Wrist
|
Observation
• • •
|
|
Tenderness
• • •
|
Wrist Orthos
• • •
|
|
Wrist ROM
• • •
|
|
|
Left Wrist
|
Observation
• • •
|
|
Tenderness
• • •
|
Wrist Orthos
• • •
|
|
Wrist ROM
• • •
|
|
|
|
|
|
Right Hand/Fingers
|
Observation
• • •
|
|
Tenderness
• • •
|
Orthos
• • •
|
|
Hand ROM
• • •
|
No Tenderness
|
|
Left Hand/Fingers
|
Observation
• • •
|
|
Tenderness
• • •
|
Hand ROM
• • •
|
|
Orthos
• • •
|
No Tenderness
|
|
|
|
|
Right Hip
|
|
|
NO right Hip pain
|
|
|
Tenderness
• • •
|
Observation
• • •
|
|
Orthos
• • •
|
Hip ROM
• • •
|
|
Left Hip
|
|
|
Tenderness
• • •
|
Observation
• • •
|
|
Orthos
• • •
|
Hip ROM
• • •
|
|
Right Thigh
|
Left Thigh
|
|
Observation
• • •
|
Tenderness
• • •
|
|
|
|
|
Right knee
|
|
|
NO knee pain
|
Observation
• • •
|
|
Tenderness
• • •
|
Orthos
• • •
|
|
Knee ROM
• • •
|
|
|
Left Knee
|
Tenderness
• • •
|
|
Observation
• • •
|
Knee ROM
• • •
|
|
Orthos
• • •
|
|
|
Ortho knee
|
McMurray's Sign (+) Left
|
|
McMurray's Sign (+) Right
|
Tinel's Sign (+)left
|
|
Tinel's Sign (+)right
|
Apley's Distraction Test (+) left
|
|
Apley's Distraction Test (+) right
|
|
|
Right Ankle
|
Left Ankle
|
|
Tenderness
• • •
|
Observation
• • •
|
|
Ankle ROM
• • •
|
Ankle Orthos
• • •
|
|
|
|
|
Right Foot
|
Left Foot
|
|
Tenderness
• • •
|
Observation
• • •
|
|
Foot ROM
• • •
|
Foot Orthopedic Test
• • •
|
|
Right lower leg
|
Left Lower Leg
|
|
Tenderness
• • •
|
Leg Comments
|
|
Muscle Pain/Tenderness/Spasms
• • •
|
Observation
• • •
|
|
|
|
|
Reflexes
|
Reflex bilateral
• • •
|
|
Reflex Right
• • •
|
Reflex Left
• • •
|
|
|
|
|
Dermatomes
|
dermatomes deficit?
• • •
|
|
|
|
|
Muscle Testing Brief
|
Muscle Testing result
• • •
|
|
|
|
|
Xray performed
|
Xray findings?
|
|
|
|
|
Assessment and Plan
|
assessment
|
|
|
|
|
PT recommendations
• • •
|
PT Recommendation Comments
|
|
Referrals
• • •
|
Referral Comments
|
