Objective assessment Objective notes

  • cough
    HIV
  • dizzinessnocturnal pain/ drop attacks/
  • coughspeaking/ swallowing problem

  • dizziness
    dizziness
  • coughcancer/ inflammatory arthritis
  • dizziness
    TB
  • cough
    weight loss/ fevers
  • dizziness
    less than 20/ more than 55
  • cough
    double vision
  • cough
    severe pain
  • cough
    spinal cord compression
  • cough
    significant vertebral tenderness
  • cough
    neck trauma/ surgery
  • cough
    preceding trauma or neck surgery

Please seek medical help if any of the above apply or else confirm that you have checked that none do.

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      Health check Before you begin, have you experienced any of the following? If yes, seek doctor as soon as possible. 1: Night sweats? 2: Recent fever? 3: Change in bladder/bowel habits, more specifically urine retention/faecal incontinence? 4: Unexplained weight loss? 5: Cough more than 3 weeks duration +\- blood in sputum? 6: Pain down both legs? 7: Poor controlled leg movement? 8: Loss of feeling down both legs or around buttocks or inner surface of thighs?
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Objective Diagnosis:

please make a note of your diagnosis number and name that appears here before clicking the 'next' button

 

Lumbar objective analysis

Has there been a recent accident, fall or trauma?

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Lumbar objective analysis

Has there been a sudden onset of low back pain following an action of lifting or twisting?

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Lumbar objective analysis

Bending forwards, is it painful?

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Lumbar objective analysis

Bending backwards, is it painful?

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Lumbar objective analysis

Bending to the right and left, is it painful?

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Lumbar objective analysis

Is the patient standing with a lateral pelvic shift?

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Lumbar objective analysis

Palpate Lumbar segments, is it painful?

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Lumbar objective analysis

Sitting slouched, straighten patient’s leg, lift toes, and bend head forward. Is it painful or is altered sensation felt? (slump test)

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Lumbar objective analysis

When therapist lifts painful leg straight up into the air, is it painful or is altered sensation felt? Patient may lift head to test further.

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Lumbar objective analysis

Test reflexes, myotomes and dermatomes. Are some positive? (refer to library for tests)

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Lumbar objective analysis

11 Palpate Lx segments, is it painful and is stiffness felt?

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Lumbar objective analysis

Is patient over 50yrs old?

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Lumbar objective analysis

When walking up hill or bent forward, is it less painful?

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Lumbar objective analysis

Is increased muscle tension evident in muscles along the back?

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Lumbar objective analysis

Feel the muscle bellies along the lower spine and above the pelvis is it painful to touch?

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Lumbar objective analysis

Is the lumbar segment painful to tap locally?

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Lumbar objective analysis

Pick up skin, and roll it between fingers. Does it feel painful and tight?

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Objective notes alert

Things to observe:

Here, we outline the objective results of your assessment, the progress towards functional goals and any treatments performed. Include details of any interventions, as well as frequency, duration and equipment used. The therapist should indicate changes in the patient's status, as well as communication with colleagues, family or carers.

Try to avoid:

  • Giving no detail
  • Summary detail such as: "ROM exercises given"

essentially, note:

  • range of movement (split into passive and active)
  • muscle strength
  • neurological assessment
  • gait
  • function

Using notes:

Simply type a note and press "Enter" key. You can edit existing notes or delete a note. To delete all your notes, use "Clear". However, as this will remove all notes on this page it is advised to copy and paste them into a document and store them elsewhere before clearing them here.

Lumbar Objective Assessment notes

 

my Objective notes symbol objective

(after listening to my patient's account and from observing all signs and clues given)

  • My observations are...

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(use info button below for guidance)

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