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Subjective and Objective Examination for Molly

Patient Name/ Date of Birth: 45 year-old female


Reason for referral:
Medical Diagnosis/ Health Condition:
Primary Language:
Subjective Examination/ Patient Interview
Patient Goals: get back to work
Personal Factors: Her hobbies include regular household activities and running. She is a mother of 2 daughters
(10 and 15 years old)
Environmental Factors: works as a nurse in a nursing home; has been placed on one week of leave of absence
due to her injury
Body Chart: deep ache, constant/ variable
Structures that underlie area of symptoms:

Structures that refer pain to the area of symptoms or


contribute to the area of pain:

Consider non-musculoskeletal structures that refer to area


of symptoms:

STOP! A question for you: Based on the body chart what is your hypothesis/hypotheses?
Activity Limitations: (establish irritability)
Aggravating Factors:
1. Attempting to do house-hold work
2. Walking and running
3. Repetitive stair climbing
Ease Factors:
1. Avoiding house-hold work, stair-climbing and evening outside walk and run
2. Lying down
3. taking medication
24 hour: AM: feels best
PM: feels increased pain

Day: depends on the amount of work


Night: no pain (takes medication)
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Subjective and Objective Examination for Molly


Subjective Examination/ Patient Interview (continued)
Current History: Three days ago, the patient was walking to her car after work at night, she tripped over a
piece of rock and fell forward on her hands/elbows, more on the left side and left shoulder. She experienced
pain in low back and left buttock region. She was able to walk back to her work and was seen by a physician
next morning. She was given anti-inflammatory medication, a week off from work and a physical therapy
prescription. The intensity of pain had worsened the next morning. However, at present the intensity has
lessened with medication; the location of pain is primary in the left buttock area. She is scheduled to return to
work in one week after visiting her work-comp physician.
Past History: no history of intense back or hip pain. However, she reports occasional mild backache after a
long busy day, which she relates to aging and possible arthritis.
Review of Systems (Body Structure/ Body Function Impairments): clear
General Health:
Malaise:
Chills/ Sweats/ Fever:
Unexplained Weight Loss/ Gain:
Cardiovascular/ Hematological
Fatigue/ Weakness:
Paresthesia/ Numbness:
Dizziness/ lightheadedness:
Musculoskeletal
Weakness:
Cough/ Sneeze:
Neurological
Paresthesia/ Numbness:
Integumentary
Skin changes:
Gastrointestinal
Bowel or bladder:
Nausea:
Metabolic
Diabetes:
Medications:
Diagnostic Tests: Consider your working hypothesis, what would be the diagnostic test most likely performed
on this patient?

Subjective and Objective Examination for Molly


Objective Examination Tests and Measures
Physical Impairment Measures
Standing:
Observation: no obvious deformity / shift / abnormal pattern is noted / navicular drop on left
LS ROM: WFL but extension is slightly limited and reproduces SI pain; left side-flexion is full but
reproduces L SI pain: flexion: PSIS on left moves more superior with flexion, no pain
Positional SIJ test/ Surface palpation: ASIS lower on left; iliac crest =; PSIS =
Hip ROM (iliosacral motion): hip flexion (Gillet): decrease posterior glide on the left; patient reports pain
in the L buttock area. Hip extension: WNL
Functional test: single leg balance (able to balance on left but reports pain)
Sitting:
Sitting Forward Flexion: normal
Positional test all negative
Supine:
Pain provocation tests: FABER: anterior and posterior hip pain; gaenslens: positive; thigh thrust:
positive
Leg Length Discrepancy: no apparent leg length discrepancy noted
SLR: form and force closure force closer helps to decrease pain with SLR; however the patient is still
unable to lift L leg (SLR)
Side lying: lumbar stability test: negative
Prone:
Central PA: mild ache at L5-SI segment
Palpation: pain over left buttock