WORKSHEET 4

ID#: __________________________
Note: Attach this sheet as your cover page !se ye""o#$pa% paper &or your a's#ers
I WRITIN( THE ASSESS)ENT *A+ ,ONTENT
A With the i'&or-atio' give' i' the 'e.t / pages0 &or-u"ate the Assess-e't *A+
portio' o& a' I'itia" Eva"uatio' usi'g the usua" 'o'$1u'ctio'a" Outco-es
Reporti'g sty"e *23 pts+
II WRITIN( THE 45AN *4+ ,ONTENT
A With the Assess-e't *A+ portio' o& a' I'itia" Eva"uatio' that you &or-u"ate% i'
part I0 -a6e the 4"a' *4+ portio' usi'g the &o""o#i'g &or-at 7 re8uire-e'ts
Su9stitute the italicized ite-s as ho# you #ish the- to 9e *23 pts+
4: 4t #i"" 9e see' * frequency + as a' * treatment setting status + &or * initial total
treatment sessio's+ T. sessio's #ith the &o""o#i'g 4T ).:
: ;
Ho-e I'structio's:
: ;
4t E%ucatio':
: ;
IDENTIFYING DATA:
Na-e: (S)
Age: /< y=o
A%%ress: :3 1air"a'e >i""age0 ?rgy (ua%a"upe0
,e9u ,ity
Se.: @
Natio'a"ity: 1i"ipi'o
,ivi" Status: Si'g"e
Occupatio': !'e-p"oye%
Re"igio': Ro-a' ,atho"ic
Ha'%e%'ess: *R+
Re&erri'g )D: Dr Arturo )e%ia'o
Date o& Re&erra": Nove-9er :A0 /33B
4hysiatrist: Dr Corge' 5i-
Date o& ,o'su"tatio': Nove-9er /30 /33B
D.: *R+ ,o""eDs &. s=p c"ose% re%uctio' 7 cast
i--o9i"iEatio'
)e%s: No'e
Date o& Eva"uatio': Ca'uary F:0 /33A
S: C/C: 4t c=o i'ter-itte't g'a#i'g pai' o' *R+ &orear- c a' i'te'sity o& 2=:3 o' a visua" a'a"og
pai' sca"e 'oc *3G'o pai'H :G-i'i-a" pai'H :3G#orst possi9"e pai'+H pai' is aggravate%
upo' -ove-e't 7 is re"ieve% 9y restH a"so 9ri'gs %i&&icu"ty &or pt i' activities re8uiri'g
use o& his *R+ !E
HPI: Octo9er :30 /33B *p-+
$ pt #as thro#' o&& a s6ate9oar% c his *R+ ha'% hitti'g the grou'% &irst
$ #as rushe% to ,e9u >e"eE (e'era" Hospita"
$ u'%er#e't I$ray #hich revea"e% a c"ose% co-p"ete &. %ista" :=F o& *R+ ra%ius c %orsa"
%isp"ace-e't
$ #as atte'%e% to 9y Dr Arturo )e%ia'o
$ u'%er#e't c"ose% re%uctio'0 #as app"ie% c a "o'g ar- cast 7 #as prescri9e% c
>o"tare' 233
Octo9er :B0 /33B
$ #as D=, 7 #as a%vise% to co't )e%s &or : -o
Nove-9er :A0 /33B
$ #e't 9ac6 to see Dr )e%ia'o &or re-ova" o& cast
$ I$ray #as reta6e' #hich revea"e% co-p"ete u'io' o& *R+ ra%ius
$ #as a%vise% to D=, )e%s
$ #as re&erre% to Dr Corge' 5i- &or 4TR &or *R+ ,o""eDs &. s=p c"ose% re%uctio' 7 cast
i--o9i"iEatio'
Nove-9er /30 /33B
$ co'su"te% Dr 5i- o' 7 #as re&erre% &or 4TR J ,e9u >e"eE (e'era" Hospita"
PMH: %e'ies a'y previous hospita"iEatio'
HFD: 4t )ater'a" 4ater'a"
H4N *$+ *$+ *$+
RA *$+ *K+ *$+
,A *$+ *$+ *$+
D) *$+ *$+ *$+
Asth-a *$+ *$+ *$+
,ar%iac %isease *$+ *K+ *$+
FDA: %e'ies a'y a""ergy
Home Situation: states "ives c his pare'ts i' a 9u'ga"o# house s sig'i&ica't 9arriers #ithi'
the house
Pt.s Lifestyle: states is usua""y out o& the house 7 practices s6ate9oar% stu'ts De'ies
9ei'g a' a"coho"ic 9everage %ri'6er 7 s-o6er
Pt.s Goal: %esires to 9e a9"e to retur' to s6ate9oar%i'g to 9e a9"e to co-pete i'
s6ate9oar% co-petitio's
O: INSPECTIN:
!e"all Im#"ession:
)e'ta" A"ert'ess: a"ertH orie'te%IFH c=c=c
(e'era" Appeara'ce: -eso-orphicH a-9u"atoryH 'o scarsH 'o co'tractures
,o--u'icatio' S6i""s: goo%
CA$DI%ASC&LA$ ASSESSMENT:
%ital Si'ns: L T. -etho%="ocatio'=positio'
?4 : *--Hg+ :/3=B3 *5+ 9rachia" artery0 auscu"tatory0 sitti'g
4R : *9p-+ <2 *5+ ra%ia" artery0 pa"patory0 sitti'g
RR : *cp-+ :M Diaphrag-atic0 regu"ar0 sitti'g
PALPATIN: *K+ -usc"e spas- J N &orear-H *K+ (r : te'%er'ess J %ista" :=F o& N &orear-H 'o
e%e-aH 'o crepitatio'H 'or-other-ic
NE&$LGIC ASSESSMENT:
Sensation: :33O i'tact a"" over the 9o%y as to super&icia" pai'0 "ight touch 7 pressure usi'g 9"u't
pi'0 9rush 7 %igita" pressure0 respective"y
$efle(es:
)SR = DTR: *R+ *5+ 5ege'%: 3Gare&"e.ia
KGhypore&"e.ia
KK KK KK KK KKG'or-ore&"e.ia
KK KK KKKGhyperre&"e.ia
KK KK KKKKGc"o'us
KK KK
Sig: 'or-ore&"e.ive o' a""$4Ds
C"anial Ne"!e Assessment: Not assesse%
M&SC&LS)ELETAL ASSESSMENT:
*oint Play: Not assesse%
$M: A"" Poi'ts are WN5 as to ARO) 7 4RO) c 'or-a" e'%$&ee"s0 e.cept:
ARO) 4RO) E'%$&ee"
N &orear- supi'atio' 3Q$43Q 3Q$42Q E-pty
N &orear- pro'atio' 3Q$F3Q 3Q$F2Q E-pty
N #rist &"e.io' 3Q$43Q 3Q$23Q E-pty
N #rist e.te'sio' 3Q$F3Q 3Q$43Q E-pty
N #rist u"'ar %eviatio' WN5 WN5 E-pty
N #rist ra%ia" %eviatio' WN5 WN5 E-pty
Sig: 5O) o' a"" N &orear- 7 #rist -otio's /Q to pai'
MMT: A"" -usc"es are gra%e% 2=20 e.cept:
N e"9o# &"e.ors G 4=2
N e"9o# e.te'sors G 4=2
N &orear- supi'ators G FK=2
N &orear- pro'ators G FK=2
N #rist &"e.ors G FK=2
N #rist e.te'sors G FK=2
N #rist u"'ar %eviators G FK=2
N #rist ra%ia" %eviators G FK=2
N &i'ger &"e.ors G FK=2
N &i'ger e.te'sors G FK=2
Sig: Wea6'ess o' a"" N &orear-0 #rist 7 &i'ger -usc"es /Q to pro"o'ge% i--o9i"ity
M+T: Not assesse%
LGM: Not assesse%
LLD: Not assesse%
PST&$AL ASSESSMENT: No postura" %eviatio' 'ote%
GAIT ASSESSMENT: No gait %eviatio' 'ote%
F&NCTINAL ASSESSMENT:
ADL: I'%epe'%e't i' a"" AD50 e.cept:
Eati'gG-o%erate %i&&icu"ty usi'g N !E i' usi'g a spoo' 7 ho"%i'g a g"ass
SPECIAL TESTS: 'o specia" tests per&or-e% /Q to post$op co'%itio'