By

Dr.Ada Anjumn
Name:
Age/Sex:
Occupation:
Address:
Contact No:
Marital Status:

Chief Complaint:

Case sheet study:

History
Present illness
- Mental
- Sleep
- Speech
Aphasia
Dysphonia
Dysarthria
Dyslexia
Dysgraphia
- Attack of Loss of Consciousness
- Headache
Duration
- Special part of the day
Character
Situation
- Tenderness
- Visual disturbances
- Vomitting
- Vertigo
- Any injury of the head
- Cough/ Sneeze effect
Visual disorder:
- onset
- frequency
- duration
Motor Disorders
- lack of coordination
- weakness – Proximal/ distal
- involuntary movement
- relieving factor
- precipitating factor
Sensory disorders:
- onset
- duration
- frequency
- Pain
- numbness/tingling
- site
- relieving factor
- precipitating factor
Spinchtor disorders
- onset
- duration
- frequency
- difficulty in control for incontinence /
retention
- anal control
- bladder control
Pain history:
- Site
- Side
- Duration
- Type
- Nature
- Radiation
- Aggravating factor
- Relieving factor
Past History:
- convulsion
- meningitis
- infection
- enchaphalitis
- pneumonia
- jaundice - General
developmental delay
- trauma/accident
- Hge - Malnutrition
Family History:
- consanguity
- epilepsy
- disability
- cardiovascular disorders
- inflammation
- Rh Factor
Development History
- eye contact
- social smile
- head control
- side turning
- sitting
- rolling
- crawling
- standing
- walking
Socio-economical history
- education
- occupation carrier
- tobacco
- cigaratte
- alcohol

Medical history
- drug allergy
Surgical History:
- incision
- length
- duration
- procedure
Physiotherapy treatment:
- Aims
- Means
- Duration
- Place
Objective Examination:
On Observation:
General
- Built
- Posture
- Gait
- Deformity
- Facial expression
Local:
- Oedema
- Atrophy
- Scar / incision / wound
- Cyanosis - Clubbing
- Neurological grafts - Breathing
type
- Eye movement - Drains
- Ventilators - Fluid input /
output
- Instrumentation
- Monitoring - catheterization
ON PALPATION
- Texture – Dryskin / scaly / smmoth
- Warmth
- Scar
- type of edema  pitting / non pitting
- Spasm
- deformity  rigid / flexible
- tone --. Hypo / hyper
- swelling –sessile / pedunculated
- anterior fontenelle
ON EXAMINATION
General:
Vital signs
- BP
- temperature
- Respiratory rate
- Heart rate
 Glasgow coma scale

Eye Response
Motor Response
Spontaneousl 4
y Obeys command 6
To verbal 3
Localizes pain 5
stimuli
To pain 2
Flexion – 4
Never 1 withdrawl
Abnormal flexion 3
Abnormal 2
Verbal Response extension
No response 1
Oriented 5
Disoriented 4
Inappropriate 3
words
Incomprehensive 2
words
No response 1
Cognitive skill
- Listen to language
- Understanding simple / complex
commands
- Name objects
- Read correctly
- write correctly
- numerical calculation
- recognize objects
- dress himself
- copy geometric pattern
Intellectual function
- Orientation
- memory
- level of memory
Emotional state
- personal type
- emotional state
- slowness of movement
Speech
- Articulation
- Aphasia
Memory
- Short term memory
- long term memory
- recent memory
- remote memory
Cranial Nerve examination
Olfactory  Smell
Optic
- Visual acquity
- visual field
- pupil
Occulomotor
- pupil
- occular movements
- nystagmus
Trigeminal nerve
- Jaw reflex
- Corneal reflex
- motor  chewinh and clenching
- sensory  opthalmic, maxillary and
mandibular
Facial
- Moter  Blinking, blowing, frowning,
smiling,
raising of eye brow
- taste  Anterior 2/3rd of tongue
Vestibulocochlear
Glossopharyngeal
- Gag reflex
- Taste of posterior 1/3rd of tongue
Vagus
- swallowing
- observe uvula and soft palate
(asymmetry)
Accessory
- SCM
- Trapezius
Hypoglossal
- Tongue movements
MOTOR SYSTEM
Muscle tone  Hypotone / Hypertone
(Acc. to Modified
Asworth Scale)
Inspection of muscle:
Circumference
- Thigh
- calf
- Arm
- forearm
Wasting
Hypertrophy
-Drooping of shoulder
-- FAsciculations
-- Joint ROM (For each joints)
-Reflexes
 Superficial
-- Abdominal
- Plantar
 Deep
-- Biceps - Brachioradialis
-- Triceps - Quadriceps
-- Hamstrings - Tendoachilus
Sensory Examination
Superficial sensation
- light touch - Temperature
- Pressure - pain
Deep sensation
- Vibration - Crude touch
- Proprioception - Kinesthesia
Cortical sensation
- 2 point discrimination -
graphesthesia (traced fig.)
- stereognosis - Barognosis
(Recog. Of wt)
Co-ordination and balance
 Equilibrium and non – equilibrium
tests
Non – equilibrium tests
o Finger to nose
o Finger to therapist finger
o Finger to finger
o Pronation / supination
o Rebound test
o Tapping
o Heel on chin
o Drawing a circle
Equilibrium tests

Standing in a normal
Standing – feet together
Standing on one foot
Standing, laterally flex the trunk to each side
Standing – eyes closed and open (Romberg sign)
Walking, placing the heel of one foot infront of toe of opposite
foot (Tandem walking)
Walk and pivot
Walk in a circle
Stair climbing with and without handrails
Limb length measurement
- True
- Apparent
- Segmental
Posture
- in supine- in prone
- in sitting - in standing
Functional assessment
- dressing - feeding - toileting
- transfer - combing - brushing
Hand function – fine motor
function
- tip to itp
- side to pad
- cylindrical
- Spherical
- hook
Bladder and bowel
- Uninhibited - Atonic
- Autonomous
Involuntary movement:
- Chorea - Athetosis -
Gait
- Stance and Swing phase
- step length - Stride length
- cadence - toe out angle
- Base of support - ROM
Investigations
1. X – ray 3. M.R.I
2. CT Scan 4. Lumbar puncture
5. Blood test

PROVISIONAL DIAGNOSIS
Management
• Problem list
• Aims
• Means
• Report

Prognosis