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.

translate

      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?
back          

Objective Diagnosis:

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

 

Paediatric objective analysis

During normal development, was there a bad accident? (eg fall from tree or car crash)? *seek medical advice if possible

back        

Paediatric objective analysis

During normal development, did the child start to lose skills and become weak? (eg could run but now cannot walk)
*seek medical advice if possible

back        

Paediatric objective analysis

During normal development, did infection or fever occur, after which a leg or an arm become weak?
*seek medical advice if possible

back        

Paediatric objective analysis

Is there one weak arm that is held straight and close to body?
*seek medical advice if possible

back        

Paediatric objective analysis

Is the child physically well but delayed in their developmental milestones? Or is the child physically struggling?

back        

Paediatric objective analysis

Is there increased tone in both legs? (eg legs scissoring or difficult to straighten)

back        

Paediatric objective analysis

Is there increased tone in both arms? (eg arms stiff and difficult to straighten). One arm may be affected more than the other

back        

Paediatric objective analysis

Are the legs able to move more freely than the arms? (if a toddler then walking unlikely)

back        

Paediatric objective analysis

Did the child have some difficulties around birth? (eg born early, late, fast or difficult labour, cord round neck, no sound, poorly or infected)

back        

Paediatric objective analysis

Are the legs stiffer than the arms? (ie walking is possible but it is up on toes and needing some support)

back        

Paediatric objective analysis

Did the child have some difficulties around birth? (eg born early, late, fast or difficult labour, cord round neck, no sound, poorly or infected)

back        

Paediatric objective analysis

Are both legs ‘floppy’? (ie legs tend to fall into a frog leg posture and not kick or move much)

back        

Paediatric objective analysis

Does the child have ‘floppy’ arms? (ie unable to lift arms to get a toy or move them much)

back        

Paediatric objective analysis

Does the child have a ‘floppy’ head and weak back? (unable to hold head up properly or sit unaided)

back        

Paediatric objective analysis

Did the child have some difficulties around birth? (eg born early, late, fast or difficult labour, cord round neck, no sound, poorly or infected)
*move to neuromuscular conditions assessment

back        

Paediatric objective analysis

Has the child been like this from birth (or since illness) yet seems to be getting stronger?

back        

Paediatric objective analysis

Does the child have stiffness (Increased tone) or floppiness (decreased tone) on one side of the body? (arm may be worse than leg or vice versa)

back        

Paediatric objective analysis

Did the child have some difficulties around birth? (eg born early, late, fast or difficult labour, cord round neck, no sound, poorly or infected)

back        

Paediatric objective analysis

Are there variable or unwanted movements that become noticeable when the child tries to move? (sitting and standing balance can be difficult, affecting all the body)

back        

Paediatric objective analysis

Did the child have some difficulties around birth? (eg born early, late, fast or difficult labour, cord round neck, no sound, poorly or infected)

back        

Paediatric objective analysis

Are there variable or unwanted movements that become noticeable when the child tries to move? (sitting and standing balance can be difficult, affecting all the body)

back        

Paediatric objective analysis

Did the child have some difficulties around birth? (eg born early, late, fast or difficult labour, cord round neck, no sound, poorly or infected)

back        

Paediatric objective analysis

Are both arms moving equally and normally without ‘floppiness’ (low tone) or resistance (high tone)

back        

Paediatric objective analysis

Was development normal until stiffness or weakness in lower limbs developed over time?

back        

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.

Paediatric 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...

symbol analysis Save   |   symbol analysis Clear

(use info button below for guidance)

back