Chapter 1: Examination Process

PAST MEDICAL HISTORY

• Establish general information

  • age, activities, occupation, limb dominance

• Establish prior history of injury to area

  • When (in years, months, days)?

  • Number of episodes?

  • Seen by physician or other health-care provider?

  • Immobilization? If so, how long?

  • Surgery? Type?

  • Limitation in activity? Duration?

  • Residual complaints? (Full recovery?)

  • Is this a similar injury? How is it different?

• Establish general health status (medications, mental status, chronic or acute diseases, etc.)

• Establish chief complaint

  • What is the patient's level of function? What are the participation restrictions?

  • What is the primary problem and resulting activity limitations with regard to activities of daily living (ADLs) and/or sport?

  • What is the duration of the current problem?

  • Mechanism of injury?

• Active range of motion

  • Evaluate for ease of movement, pain, available ranges (quantified via goniometry)

• Manual muscle tests

  • Evaluate for pain and weakness

• Passive range of motion

  • Evaluate for difference from active ROM, pain, end-feel, available range (quantified via goniometry)

• Stress testing

  • Evaluate for increased pain and/or increased or decreased laxity relative to opposite side

• Joint play

  • Evaluate for increased pain and/or increased or decreased mobility relative to opposite side

• Provocation testing

  • Stress increases pain/symptoms and/or indicates instability

  • Self-initiated treatment (e.g., ice, rest, continue to participate) and its effectiveness

• Establish pain information

  • Pain location, type, and pattern: does it change?

  • What increases and decreases pain?

  • Pattern relative to sport-specific demands

• Establish changes in demands of activity and/or occupation

  • Changes in activity?

  • New activity pattern?

  • New equipment?

  • ADLs?

• Other relevant information

  • Pain/other symptoms anywhere else?

  • Altered sensation?

  • Crepitus, locking, or catching?

• What functional limitations does the patient demonstrate?

• What impairments cause the functional limitations?

• Which are most problematic?

• Obvious deformity

• Swelling and discoloration

• General posture

• Scars, open wounds, cuts, or abrasions

• Areas of point tenderness

• Change in tissue density (scarring, spasm, swelling, calcification)

• Deformity

• Temperature change

• Texture

• Alleviation testing

  • Application of force decreases pain or symptoms

• Sensory

  • Assess spinal nerve root and peripheral nerve sensory function

• Motor

  • Determine spinal nerve root and peripheral motor nerve function

• Reflex

  • Assess spinal level reflex function

• Capillary refill

  • Assess for adequate perfusion

• Distal pulses

  • Assess for adequate blood supply

• Include all diagnoses that have not been excluded by the differential diagnosis process.

• Ideally, the clinical diagnosis is obtained by ruling out all of the potential differential diagnoses.

• Prognosis

  • Predict probable short- and long-term outcome of the intervention

• Intervention

  • Identify treatment goals (such as return to activity) based on identified impairments, activity limitations, and participation restrictions

* Compare bilaterally