Objective notesbjective assessment


Objective notes

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
  • bowel
    bladder/bowel incontinence
  • wobbly
    loss of feeling in both legs

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

 
 

Print version

 

Has there been a recent accident, fall or trauma?
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Has the patient got any significant limb weakness/decreased sensation, loss of bowel/bladder, positive Babinski, Clonus or Hoffmans test?
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Does the pain go down the neck into their shoulder / arm / hand?
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Is the pain central, localized to the neck?
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Does the pain get worse on activity?
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Is there a decrease in range of movement to the neck or pain on movement?
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Is there muscle spasm or muscle tightness?
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Does the pain / numbness correlate to a dermatome/ myotome?
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Does the pain / symptoms get worse with the Spurlings test?
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Is the pain sensitive to Upper Limb Tension Tests (ULTT)?
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Any positive testing for myotomes, dermatomes or reflexes?
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Was the pain a progressive onset over days or weeks?
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Is pain better after activity / movement?
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Is the pain worse on waking in the morning or after rest and is the patient over 50 yrs old?
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Is there multi-joint stiffness or decreased range of movement?
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Has the patient got any significant limb weakness/decreased sensation, loss of bowel/bladder, positive Babinski, Clonus or Hoffmans test?
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Is there localised muscular tenderness to the neck?
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Objective assessments (print-out version)


1: Has there been a recent accident, fall or trauma?
Yes = see a doctor; No = go to 2


2: Do you cough up blood?
Yes = see a doctor; No = go to 34

3: Is the in-breath louder than the out-breath (stridor)? Yes = see a doctor; No = go to 4

4: Is the patient out of breath when speaking? (note: do their shoulders move to help them breathe) Yes = severe breathlessness; No = go to 5

5: Do you now struggle with a normal activity such as walking, which didn’t happen before? Yes = ADL limited by breathlessness; No = go to 6

6: Note time taken for sit to stand test)? Time taken? = ; go to 7

7: using Borg scale, patient points to the level that describes their breathlessness? Note answer given = ; go to 8

8: can you hear crackles with your ear or stethoscope? Yes = sputum needs clearance; No = go to 9

9: Can you feel the crackles with your hand?? Yes = sputum needs clearance; No = go to 10

10: Are the crackles high in the lungs? Yes = go to 11; No = sputum needs clearance

11: Do you hear bronchial breathing or reduced breath sounds? Yes = go to 12; No = reduced breath in lungs, go to doctor

12: Do you feel aches around your shoulders or chest from coughing and bringing up sputum? Yes = needs pain relief; No = go to 13

13: Are you drinking enough water? Yes = go to 14; No = de-hydrated

14: Do you (the patient) have a lot of sputum? Yes = excess sputum; No = 15

15: Does the amount of sputum bother you? Yes = Education in sputum clearance; No = go to 16

16: Has your sputum changed colour or is it thicker? Yes = go to 17; No = go to 19

17: Do you have bronchiectasis or COPD? Yes = go to doctor; No = go to 18

18: Do you feel ill/ have a temperature? Yes = consider going to doctor for potential infection; No = go to 19

19: Do you have problem with bringing up sputum? Yes = go to 20; No = go to 23

20: Is the problem of bringing up sputum due to pain?? Yes = pain in sputum retention; No = go to 21

21: Is the problem of bringing up sputum due to weakness? Yes = weakness causing sputum retention; No = go to 22

22: Is the problem of bringing up sputum due to a social reason or embarrassment? Yes: Embarrassment; No: go to 23

23: Does the problem of bringing up sputum cause other problems such as wetting yourself? Y: Causes wetting; No: go to 24

24: Outcome measures (done after treatment): Is the sputum now clearer? Y: go to 25; No: repeat treatment

25: Outcome measures (done after treatment): Can the patient now manage their own secretions? Y: (finish); No: repeat treatment