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Patient Profile

Patient Profile. Age, Gender, Occupation, Recreation, Family Chief complaint: (The reason the patient is seeking treatment, in their “ own words ” ). Patient Self Report Inventories . Numeric Pain Rating Scale (NPRS) Best in the last week: **/10 Worst in the last week: **/10

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Patient Profile

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  1. Patient Profile • Age, Gender, Occupation, Recreation, Family • Chief complaint: (The reason the patient is seeking treatment, in their “own words”)

  2. Patient Self Report Inventories • Numeric Pain Rating Scale (NPRS) • Best in the last week: **/10 • Worst in the last week: **/10 • Average in the last week: **/10 • Neck Disability Index (NDI): **% • Fear Avoidance Belief Scale (FABQ): **/64 • Physical Activity Subscale: **/ 24 • Work Subscale : **/42 • Depression Screen: • During the past month have you been bothered by feeling down, depressed or hopeless? • During the past month have you been bothered by little interest or pleasure in doing things.

  3. Patient Specific Functional Scale

  4. Body Chart P1: P2: P3: P4: • Relationship of Areas

  5. 1)Insert Text Box then type an x or copy and paste from existing2) Resize auto shapes at will 3) When body chart is complete: Group symbols P1: X P2: P3: P4:

  6. History of Current Episode • Duration of symptoms: • Mechanism of onset: • Progression of symptoms since onset: • Current status (improving, static, worsening): • Treatment and response:

  7. Previous History • Previous Episodes: • Contributing Factors: • Previous Treatment: • Medical History/Co-morbidities:

  8. Aggravating/Easing Factors Worst area: Best: Preferred Position of Rest: Easing positions or activitiesL

  9. 24 Hour Behavior • Night: • A.M. • Day:

  10. Red Flag Screen • General Health • Age 55 with history of cancer • Cord: Clumsiness in hands, disturbance of gait suggestive of spasticity: • Cauda Equina: • Steroids or anticoagulants: • Numbness and tingling in the hands and feet: • 5 D’s (dizziness, diploplia, dysphagia, dysarthria, drop attacks)

  11. Yellow Flag Screen • FABQ Score: • Depression Inventory: • Behaviors suggestive if depression • Use of extended rest • Preference for passive treatment • Withdrawal from daily activities • Reports of extremely high pain • Excessive reliance on aids or appliance • Self Medication

  12. From the Body Chart: Structures to be Examined

  13. Current Hypotheses: In order of priority

  14. Presentation

  15. Plan of the Objective Examination • Does the nature of the condition or presence of co-morbidities indicate caution? • Will you limit the amount of examination? • Will you limit the vigor? : • Examine to P1 • Examine to limit of active range • Add overpressure • Use repeated movements • Use sustained overpressure, combined movements • Are special tests indicated? • What structures will you examine on day 1?

  16. Plan of the Objective Examination • Do you expect the comparable sign to be easy or hard to find? • Why? • What test or movement do you think will reproduce the comparable sign? • Are there contributing factors which must be examined?

  17. Objective Examination • Observation • Affect: • Fitness: • Gait: • Posture • Habitual: • Spinal curvature: • Signs of muscle imbalance: • Functional Screens

  18. Neurological Examination • Reflex: • Dermatome: • Myotome: • Hoffman’s: • Clonus: • Babinski: • Cranial Nerve examination : • Upper cervical ligamentous stability • Tectoral Membrane: • Transverse: • Alar: • Cervical Artery Screen:

  19. Active Range of Motion Cervical

  20. Active Range of Motion Thoracic

  21. Other tests

  22. Palpation Findings: PPIVMS Motion Tested: Side gliding

  23. Palpation Examination: Tissues at rest

  24. Palpation Findings: PAIVMS

  25. Reassessment following Palpation

  26. Assessment Following the Objective: Review and re-rank your hypotheses

  27. Select Subjection and Objective Asterisks

  28. Treatment Day 1

  29. Assessment Following the Treatment: 1)Review and re-rank your hypotheses2) What is the impact of treatment on the working hypothesis

  30. Assessment Following Treatment • Working hypothesis: • Was you initial hypothesis confirmed, clarified, modified or rejected? • Can the disorder be classified or is a clinical syndrome apparent? • Did your assessment of Presentation change? • Severity: • Irritability: • Nature : • Stage: • Stability: • Did you accomplish what you wanted/needed to do in the first session??

  31. Prognosis • Expected level and rate of recovery: • Time frame and number of visits: • Factors which will promote or impede recovery: • Likelihood of recurrence:

  32. Plan for the next session

  33. Visit # 2 Assessment at the Start of Session

  34. Treatment Visit 2

  35. Plan for the next session

  36. Assessment Functional Asterisks and Impairments

  37. Reassessment Patient Self Reports

  38. Global Rating of Change Scale

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