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

 

Neck objective analysis

Has there been a recent accident, fall or trauma?

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Neck objective analysis

Has the patient got any significant limb weakness/decreased sensation, loss of bowel/bladder, positive Babinski, Clonus or Hoffmans test?

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Neck objective analysis

Does the pain go down the neck into their shoulder / arm / hand?

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Neck objective analysis

Is the pain central, localized to the neck?

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Neck objective analysis

Does the pain get worse on activity?

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Neck objective analysis

Is there a decrease in range of movement to the neck or pain on movement?

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Neck objective analysis

Is there muscle spasm or muscle tightness?

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Neck objective analysis

Does the pain / numbness correlate to a dermatome/ myotome?

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Neck objective analysis

Does the pain / symptoms get worse with the Spurlings test?

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Neck objective analysis

Is the pain sensitive to Upper Limb Tension Tests (ULTT)?

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Neck objective analysis

Any positive testing for myotomes, dermatomes or reflexes?

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Neck objective analysis

Was the pain a progressive onset over days or weeks?

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Neck objective analysis

Is pain better after activity / movement?

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Neck objective analysis

Is the pain worse on waking in the morning or after rest and is the patient over 50 yrs old?

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Neck objective analysis

Is there multi-joint stiffness or decreased range of movement?

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Neck objective analysis

Has the patient got any significant limb weakness/decreased sensation, loss of bowel/bladder, positive Babinski, Clonus or Hoffmans test?

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Neck objective analysis

Is there localised muscular tenderness to the neck?

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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.

Neck 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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