Tilak Maharashtra Vidyapeeth

DEPARTMENT OF PHYSIOTHERAPY
Patient Evaluation Format

NEUROLOGY
Demographic Data
Name: Mr.Vikas Ramchandra Alur

Age: 68 years

Gender: Male

Occupation: Accountant ( Retired )

Hand Dominance:

Hospital number:

Date of Admission:

Date of Assessment: 23/08/18

Chief Complaint: Pain at right shoulder since 2 months

Pain, unconsciousness, disoriented ,not responding, ADL

difficulties, inabilities with duration(e.g. walk)

Ambulation (unable to walk, climbing stairs in descending)

Bed activity(rolling, sitting up , moving in bed)

Dressing (buttoning, lower limb)

Eating, Toileting(sensation, squatting, getting up and sits)

Weakness sensory and balance problem (unable to feel hot, cold
numbness, chappal slipping, fall during walking , fall while sitting up and
down

Dizziness

HOPI:

History of present illness

Date and mode of onset (sudden/ gradual/ acute/ subacute / chronic)

Nature and severity, site of symptoms and progression, frequency (no. of

times/ days/hours)

Associated symptoms (fracture, injury, headache, vomiting, etc.)

Past medical history: Diabetes Mellitus since 9 years

Past surgical history: None

Occupational history: Accountant

(retired since 12 years)

Personal history:

Sleep: Not disturbed

Diet: Mixed

Appetite: Normal

Bowel: Clear

Bladder: Continent

Addictions:

Environmental history : Lives in a bungalow (Ground floor) with Indian

toilet setup, Switches at level

(area, location, no. of rooms, type of toilet, width of passage)

Family history: Cancer ( father & brother)

General examination:-

Mode of ambulation (dependent/independent/walking aids):

Gait examination:-

Type of gait:

Build: Mesomorphic

Mode of ventilation:

Type of respiration: Abdominothoracic

Pattern of respiration:

Posture

Attitude of limb

Other relevant features

Tropic changes
Wound edema sutures

Location

Extent

General Examination

Vital signs : Temperature :

Blood pressure :

Heart rate :

Pulse rate :

Respiratory rate :

Higher Mental Functions:-

Level of Consciousness : ( alert ,drowsy, conscious)

Glasgow coma scale

Eye opening response
Spontaneous 4
To speech 3
To pain 2
No response 1
Best Motor Response
Follows motor commands 6
Localizes 5
Withdraws 4
Abnormal flexion 3
Extensor response 2
No response 1
Verbal Response
Oriented 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Total : /15

Behaviour:

Orientation:

Minimental State Examination:-

 Maximum Patients score Questions
score
5 “What is the year? Season? Date? Day of the week?
Month?”
5 “Where are we now: State? County? Town/city?
Hospital? Floor?”
3 The examiner names three unrelated objects clearly
and slowly, then asks the patient to name all three
of them. The patient’s response is used for scoring.
The examiner repeats them until patient learns all of
them, if possible. Number of trials: __________
5 “I would like you to count backward from 100 by
sevens.” (93, 86, 79,72, 65, …) Stop after five
answers. Alternative: “Spell WORLD backwards.” (D-
L-R-O-W)
3 “Earlier I told you the names of three things. Can
you tell me what those were?”
2 Show the patient two simple objects, such as a
wristwatch and a pencil, and ask the patient to
name them.
1 “Repeat the phrase: ‘No ifs, ands, or buts.’”
3 “Take the paper in your right hand, fold it in half,
and put it on the floor.” (The examiner gives the
patient a piece of blank paper.)
1 “Please read this and do what it says.” (Written
instruction is “Close your eyes.”)
1 “Make up and write a sentence about anything.”
(This sentence must contain a noun
“Make up and write a sentence about anything.”
(This sentence must contain a noun and a verb.)
1 “Please copy this picture.” (The examiner gives the
patient a blank piece of paper and asks him/her to
draw the symbol below. All 10 angles must be
present and two must intersect.)

30 TOTAL

 Cranial nerve Examination

Nerves Right Left

 I. Olfactory
II. Optic
III. Occulomotor
IV. Abducent
V. Trigeminal
VI. Trochlear
VII. Facial
VIII. Vestibulocochlear
IX. Glossopharyngeal
X. Vagus
XI. Spinal accessory
XII. Hypoglossal
 Sensory Examination

Superficial sensations:

i. Pain

ii. Touch

iii. Temperature

iv. Pressure

Deep sensations:

i. Kinesthesia

ii.Proprioception

iii.Vibration

Combined cortical sensations

i.Stereognosis

ii.Tactile localization

iii.Two-point discrimination

iv.Double simultaneous stimulation

v.Graphesthesia

vi.Recognition of Texture

vii.Baragnosis

Motor Examination
 Muscle tone : Normal/Hypotonia/hypertonia

Clonus

Modified Ashworth Scale :

Grade - Description

0 - No increase in muscle tone.

1 - Slight increase in muscle tone, manifested by a catch and release or by

minimal resistance at the end of the ROM when the affected part(s) is moved in
flexion or extension.

1+ - Slight increase in muscle tone, manifested by a catch, followed by minimal

resistance throughout the remainder (less than half) of the ROM.

2 - More marked increase in muscle tone through most of the ROM, but affected
part(s) easily moved.

3 - Considerable increase in muscle tone, passive movement difficult.

4 - Affected part(s) rigid in flexion or extension.

 Muscle tightness

Upper extremity Right Left

i. Shoulder adductors
ii. Elbow Flexors
iii. Wrist Flexors

Lower Extremity

i. Hip adductors
ii. Knee Extensors
iii. Knee Flexors
iv. Ankle Plantar flexors
 Grades-
1. Mild- crosses neutral but not fully
2. Moderate – only upto neutral
3. Severe – do not reach neutral

 Movement transition
1. Supine to sitting
 2. Sitting up and down
3. Squatting
 Reflexes-

Superficial-

i. Corneal
ii. Abdominal
iii. Plantar

Deep-

i. Jaw
ii. Biceps
iii. Brachioradialis
iv. Triceps
v. Finger Flexors
vi. Knee jerk
vii. Ankle jerk
 Grading of reflexes

0 – absent

+ - Diminished

++-normal

+++ - brisk

++++ - exaggerated

Balance-

Static-

Sitting- eye close

Eye open

Standing- Tandem standing

Single leg stance

Dynamic balance –

Reaching out activities

Co- ordination examination (can be performed if MMT grade more than 3)

Non- equilibrium

a. Finger to nose
b. Finger to finger
c. Alternate supination and pronation
d. Heel- shin test
e. Rebound test
f. Tapping of hand
g. Tapping of foot

Equillibrium

a. Sit to stand
b. Stand to sit
c. Romberg standing
d. Tandem walking
e. 360˚ rotation
f. Back walking
g. Step up
h. Step down

Gait:

ii. Step length

iii. Stride length
iv. Base of support

Cadence

Associated movements

Walking aids

Phases:

 Stance phase
i. Heel strike
ii. Foot flat
iii. Mid stance
iv. Heel off
v. Toe off
  Swing phase
i. Acceleration
ii. Midswing
iii. Deceleration

Type of Gait

Bladder and bowel examination:-

Voiding problem

Type of bladder (LMN or UMN)

Urgency

Frequency

Intentional

Dribbling

Type of catheter used

Bowel control

Functional evaluation

FIM

LOCOMOTION: WALK/WHEELCHAIR: Includes walking, once in a standing position, or

if using a wheelchair, once in a seated position, on a level surface. Performs safely.
Indicate the most frequent mode of locomotion (Walk or Wheelchair). If both are
used about equally, code: “Both.”

NO HELPER

7 Complete Independence—Subject walks a minimum of 150 ft (50 m) without

assistive devices. Does not use a wheelchair. Performs safely.

6 Modified Independence—Subject walks a minimum of 150ft (50 m) but uses a

brace (orthosis) or prosthesis on leg, special adaptive shoes, cane, crutches, or
walkerette; takes more than reasonable time or there are safety considerations. If
not walking, subject operates manual or motorized wheelchair independently for a
minimum of 150ft (50 m); turns around; maneuvers the chair to a table, bed, toilet;
negotiates at least a 3% grade; maneuvers on rugs and over door sills.

5 Exception (Household Ambulation)—Subject walks only short distances (a

minimum of 50ft or 17 m) independently with or without a device. Takes more than
reasonable time, or there are safety considerations, or operates a manual or
motorized wheelchair independently only short distances (a minimum of 50ft or 17
m).

HELPER

5 Supervision

If walking, subject requires standby supervision, cueing, or coaxing to go a minimum

of 150ft (50 m). If not walking, requires standby supervision, cueing, or coaxing to go
a minimum of 150ft (50 m) in wheelchair.

4 Minimal Contact Assistance—Subject performs 75% or more of locomotion effort

to go a minimum of 150ft (50 m).

3 Moderate Assistance—Subject performs 50% to 74% of locomotion effort to go a

minimum of 150ft (50 m).

2 Maximal Assistance—Subject performs 25% to 49% of locomotion effort to go a

minimum of 50ft (17 m). Requires assistance of one person only.

1 Total Assistance—Subject performs less than 25% of effort, or requires assistance

of two people, or does not walk or wheel a minimum of 50ft (17 m).

Comment: If the subject requires an assistive device for locomotion (wheelchair,

prosthesis, walker, cane, AFO, adapted shoe, and so forth), the Walk/Wheelchair
score can never be higher than level 6. The mode of locomotion (Walk or
Wheelchair) must be the same on admission and discharge. If the subject changes
mode of locomotion from admission to discharge (usually wheelchair to walking),
record the admission mode and scores based on the more frequent mode of
locomotion at discharge.

Barthel index

Bowels 0 = incontinent (or needs to be given enemata)

1 = occasional accident (once/week)

2 = continent

Patient's Score:

Bladder 0 = incontinent, or catheterized and unable to manage

1 = occasional accident (max. once per 24 hours)

2 = continent (for over 7 days)

Patient's Score:

Grooming 0 = needs help with personal care

1 = independent face/hair/teeth/shaving (implements provided)

Patient's Score:

Toilet use 0 = dependent

1 = needs some help, but can do something alone

2 = independent (on and off, dressing, wiping)

Patient's Score:

Feeding 0 = unable

1 = needs help cutting, spreading butter, etc.

2 = independent (food provided within reach)

Patient's Score:

Transfer 0 = unable – no sitting balance

1 = major help (one or two people, physical), can sit

2 = minor help (verbal or physical)

3 = independent
 Patient's Score:

Mobility 0 = immobile

1 = wheelchair independent, including corners, etc.

2 = walks with help of one person (verbal or physical)

3 = independent (but may use any aid, e.g., stick)

Patient's Score:

Dressing 0 = dependent

1 = needs help, but can do about half unaided

2 = independent (including buttons, zips, laces, etc.)

Patient's Score:

Stairs 0 = unable

1 = needs help (verbal, physical, carrying aid)

2 = independent up and down

Patient's Score:

Bathing 0 = dependent

1 = independent (or in shower)

Patient's Score:

Total Score:

Berg balance

1. Sitting to standing Instructions: Please stand up, try not to use your hands for
support.
( ) 4 able to stand without using hands and stabilizes independently
( )3 able to stand independently using hands
 ( )2 able to stand using hands after several tries
( )1 needs minimal aid to stand or stabilize
( )0 needs moderate or maximal assist to stand
2. Standing unsupported Instructions: Please stand for 2 minutes without holding.
( )4 able to stand safely 2 minutes
( )3 able to stand 2 minutes with supervision
( )2 able to stand 30 seconds unsupported
( )1 needs several tries to stand unsupported 30 seconds
( )0 unable to stand 30 seconds without support
3. Sitting with back unsupported but feet supported on floor or on a stool
Instructions: Please sit with arms folded for 2 minutes.
( )4 able to sit safely and securely 2 minutes
( )3 able to sit 2 minutes with supervision
( )2 able to sit 30 seconds
( )1 able to sit 10 seconds
( )0 unable to sit without support 10 seconds
4. Standing to sit Instructions: Please sit down.
( )4 sits safely with minimal use of hands
( )3 controls descent by using hands
( )2 uses back of legs against chair to control descent
( )1 sits independently, but has uncontrolled descent
( )0 needs assistance to sit
5. Transfers Instructions: Arrange chairs for a pivot transfer. Ask the patient to
transfer one way toward a seat without armrests and one way toward a seat
with arms. You may use two chairs or a bed/mat and a chair.
( )4 able to transfer safely with minor use of hands
()3 able to transfer safely with definite need of hands
( )2 able to transfer with verbal cuing and/or supervision
( )1 needs one person to assist
( )0 needs two people to assist or supervise to be safe
6. Standing unsupported with eyes closed Instructions: Please close your eyes and
stand still for 10 seconds.
( )4 able to stand 10 seconds safely
( )3 able to stand 10 seconds with supervision
( )2 able to stand 3 seconds
( )1 unable to keep eyes closed for 3 seconds but stands safely
( )0 needs help to keep from falling
7. Standing unsupported with feet together Instructions: Place your feet together
and stand without holding.
( )4 able to place feet together independently and stand safely 1 minute
( )3 able to place feet together independently and stand with supervision for 1
minute
 ( )2 able to place feet together independently but unable to hold for 30 seconds
( )1 needs help to assume the position but can stand for 15 seconds, feet
together
( )0 needs help to assume the position and unable to stand for 15 seconds

8. Reaching forward with outstretched arm while standing Instructions: Lift arm to
90°. Stretch out your fingers and reach forward as far as you can. (Clinician
places a ruler at the tips of the outstretched fingers—subject should not touch
the ruler when reaching.) Distance recorded is from the fingertips with the
subject in the most forward position. The subject should use both hands when
possible to avoid trunk rotation.
( )4 can reach forward confidently 20–30 cm (10 inches)
( )3 can reach forward safely 12 cm (5 inches)
( )2 can reach forward safely 5 cm (2 inches)
( )1 reaches forward but needs supervision
( )0 loses balance when trying, requires external support
9. Pick up object from the floor from a standing position Instructions: Pick up the
shoe slipper which is placed in front of your feet.
( )4 able to pick up the slipper safely and easily
( )3 able to pick up the slipper but needs supervision
( )2 unable to pick up the slipper, but reaches 2–5 cm (1–2 inches) from the
slipper and keeps balance independently
( )1 unable to pick up and needs supervision while trying
( )0 unable to try/needs assistance to keep from losing balance/falling
10. Turning to look behind over your left and right shoulders while standing
Instructions: Turn and look directly behind you over toward the left shoulder.
Repeat to the right. Examiner may pick an object to look at directly behind the
subject to encourage a better twist.
( )4 looks behind from both sides and weight shifts well
( )3 looks behind one side only, other side shows less weight shift
( )2 turns sideways only but maintains balance
( )1 needs close supervision or verbal cuing
( )0 needs assistance while turning
11. Turn 360° Instructions: Turn completely around in a full circle, pause, then turn a
full circle in the other direction.
( )4 able to turn 360° safely in 4 seconds or less
( )3 able to turn 360° safely, one side only, 4 seconds or less
( )2 able to turn 360° safely, but slowly
( )1 needs close supervision or verbal cuing
( )0 needs assistance while turning
12. Place alternate foot on step or stool while standing unsupported Instructions:
Place each foot alternately on the step stool. Continue until each foot has
touched the step stool 4 times.
( )4 able to stand independently and safely and complete 8 steps in 20 seconds
 ( )3 able to stand independently and complete 8 steps >20 seconds
( )2 able to complete 4 steps without aid with supervision
( )1 able to complete >2 steps needs minimal assistance
( )0 needs assistance to keep from falling/unable to try
13. Standing unsupported one foot in front Instructions: Demonstrate to subject.
Place one foot directly in front of the other. If you feel that you cannot place
your foot directly in front, try and step far enough ahead that the heel of your
forward foot is ahead of the toes of your other foot. To score three points, the
length of the step should exceed the length of the other foot and the width of
the stance should approximate the subject’s normal stance width.
( )4 able to place foot tandem independently and hold 30 seconds
( )3 able to place foot ahead of the other independently and hold 30 seconds
( )2 able to take a small step independently and hold 30 seconds
( )1 needs help to step but can hold 15 seconds
( ) 0 loses balance while stepping or standing
14. Standing on one leg Instructions: Stand on one leg as long as you can without
holding
( )4 able to lift leg independently and hold >10 seconds
( )3 able to lift leg independently and hold 5–10 seconds
( )2 able to lift leg independently and hold >2 seconds
( )1 tries to lift leg unable to hold 3 seconds but remains standing independently
( )0 unable to try or needs assistance to prevent fall

_________ TOTAL SCORE (Maximum 56)

Dynamic gait index

1. Gait level surface _____

Instructions: Walk at your normal speed from here to the next mark (20’)
Grading: Mark the lowest category that applies.
 (3) Normal: Walks 20’, no assistive devices, good sped, no evidence for
imbalance, normal gait pattern
(2) Mild Impairment: Walks 20’, uses assistive devices, slower speed, mild gait
deviations.
(1) Moderate Impairment: Walks 20’, slow speed, abnormal gait pattern,
evidence for imbalance.
(0) Severe Impairment: Cannot walk 20’ without assistance, severe gait
deviations or imbalance.

2. Change in gait speed _____

Instructions: Begin walking at your normal pace (for 5’), when I tell you “go,” walk as
fast as you can (for 5’). When I tell you “slow,” walk as slowly as you can (for 5’).
Grading: Mark the lowest category that applies.

(3) Normal: Able to smoothly change walking speed without loss of balance or gait
deviation. Shows a significant difference in walking speeds between normal, fast and
slow speeds.

(2) Mild Impairment: Is able to change speed but demonstrates mild gait deviations,
or not gait deviations but unable to achieve a significant change in velocity, or uses
an assistive device.

(1) Moderate Impairment: Makes only minor adjustments to walking speed, or

accomplishes a change in speed with significant gait deviations, or changes speed
but has significant gait deviations, or changes speed but loses balance but is able to
recover and continue walking.

(0) Severe Impairment: Cannot change speeds, or loses balance and has to reach for
wall or be caught.

3. Gait with horizontal head turns _____

Instructions: Begin walking at your normal pace. When I tell you to “look right,”
keep walking straight, but turn your head to the right. Keep looking to the right until
I tell you, “look left,” then keep walking straight and turn your head to the left. Keep
your head to the left until I tell you “look straight,“ then keep walking straight, but
return your head to the center.

Grading: Mark the lowest category that applies.

(3) Normal: Performs head turns smoothly with no change in gait.

(2) Mild Impairment: Performs head turns smoothly with slight change in gait
velocity, i.e., minor disruption to smooth gait path or uses walking aid.

(1) Moderate Impairment: Performs head turns with moderate change in gait
velocity, slows down, staggers but recovers, can continue to walk.
(0) Severe Impairment: Performs task with severe disruption of gait, i.e., staggers
outside 15” path, loses balance, stops, reaches for wall.

4. Gait with vertical head turns _____

Instructions: Begin walking at your normal pace. When I tell you to “look up,” keep
walking straight, but tip your head up. Keep looking up until I tell you, “look down,”
then keep walking straight and tip your head down. Keep your head down until I tell
you “look straight,“ then keep walking straight, but return your head to the center.
Grading: Mark the lowest category that applies.

(3) Normal: Performs head turns smoothly with no change in gait.

(2) Mild Impairment: Performs head turns smoothly with slight change in gait
velocity, i.e., minor disruption to smooth gait path or uses walking aid.

(1) Moderate Impairment: Performs head turns with moderate change in gait
velocity, slows down, staggers but recovers, can continue to walk.

(0) Severe Impairment: Performs task with severe disruption of gait, i.e., staggers
outside 15” path, loses balance, stops, reaches for wall.

5. Gait and pivot turn _____

Instructions: Begin walking at your normal pace. When I tell you, “turn and stop,”
turn as quickly as you can to face the opposite direction and stop.

Grading: Mark the lowest category that applies.

(3) Normal: Pivot turns safely within 3 seconds and stops quickly with no loss of
balance.

(2) Mild Impairment: Pivot turns safely in > 3 seconds and stops with no loss of
balance.

(1) Moderate Impairment: Turns slowly, requires verbal cueing, requires several
small steps to catch balance following turn and stop.

(0) Severe Impairment: Cannot turn safely, requires assistance to turn and stop.

6. Step over obstacle ____

Instructions: Begin walking at your normal speed. When you come to the shoebox,
step over it, not around it, and keep walking.

Grading: Mark the lowest category that applies.

(3) Normal: Is able to step over the box without changing gait speed, no evidence
of imbalance.
(2) Mild Impairment: Is able to step over box, but must slow down and adjust steps
to clear box safely.

(1) Moderate Impairment: Is able to step over box but must stop, then step over.
May require verbal cueing.

(0) Severe Impairment: Cannot perform without assistance.

7. Step around obstacles _____

Instructions: Begin walking at normal speed. When you come to the first cone
(about 6’ away), walk around the right side of it. When you come to the second cone
(6’ past first cone), walk around it to the left.

Grading: Mark the lowest category that applies.

(3) Normal: Is able to walk around cones safely without changing gait speed; no
evidence of imbalance.

(2) Mild Impairment: Is able to step around both cones, but must slow down and
adjust steps to clear cones.

(1) Moderate Impairment: Is able to clear cones but must significantly slow, speed to
accomplish task, or requires verbal cueing.

(0) Severe Impairment: Unable to clear cones, walks into one or both cones, or
requires physical assistance.

8. Steps _____

Instructions: Walk up these stairs as you would at home, i.e., using the railing if
necessary. At the top, turn around and walk down.

Grading: Mark the lowest category that applies.

(3) Normal: Alternating feet, no rail.

(2) Mild Impairment: Alternating feet, must use rail.

(1) Moderate Impairment: Two feet to a stair, must use rail.

(0) Severe Impairment: Cannot do safely.

TOTAL SCORE: ___ / 24

Investigations: