Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination Page 12
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30Table 4. Physical examination form (reason for referral indicated in green).
PATIENT PHYSICAL EXAMINATION
Patient Name_____________________________________________________ Date______________
OBSERVATION
Skin
Red spider veins on ears and cheeks
Dry skin
Dry skin
Brittle hair
Lemon-yellow discoloration skin
Papilledema
Clubbing fi ngernails
Trophic changes skin
Peripheral oedema
Posture
Increased kyphoscoliosis
Craniocervical junction abnormalities
Lateral head tilt
Forward head posture
Eyes
Pigmented corneal rings
Red spider veins corner of the eyes
Vertical misalignment L high
Vertical misalignment R high
Horizontal misalignment
Corrective lateral head tilt when covering one eye in case of vertical misalignment
Other ____________________________________________________________________________________
VITAL SIGNS
Blood pressure
Arm systolic difference (≥45 mm Hg)
+/- ________________________________________
Heart rate
Palpitations
+/-_____________________________________________________________
Sit-to-stand test
Blood pressure (decrease ≥20 mm Hg)
+/-
Heart rate (increase ≥20 bpm)
+/-
Lightheadedness___________________________________________________________
Auscultation
Carotid bruit
+/-
Cardiac abnormalities
+/-______________________________________
GAIT ASSESSMENT________________________________________________________________________
_________________________________________________________________________________________
Wide-based gait
Steppage gait
Titubation
Improved gait with assistive device
Unilateral deviation when walking straight line
Diffi culty with concurrent head rotation
Unable to walk tandem gait
Wildly lurching without loss of balance
VESTIBULO-SPINAL EXAMINATION
Single leg stance
L ____sec
R ____sec _______________________________________________
Romberg
Eyes open________________________
Eyes closed ______________________
Sharpened Romberg
Eyes open________________________
Eyes closed ______________________
CTSIB
Level, eyes open___________________
Level, eyes closed _________________
Foam, eyes open___________________
Foam, eyes closed_________________
Fukuda step test
Rotate > 30º +/-
Rotate L/ R
Forward displacement > 50 cm +/-
CRANIAL NERVE EXAMINATION
_____________________________________________________________
Cranial nerve
Test
L/R
I.
Olfactory
Identify different odors
+
-
II.
Optic
Test visual fi elds (Confrontation method)
+
-
III.
Oculomotor
Upward, downward, and medial gaze
+
-
IV.
Trochlear
Downward and lateral gaze
+
-
V.
Trigeminal
Corneal refl ex, face sensation, clench teeth
+
-
VI.
Abducens
Lateral gaze
+
-
VII. Facial
Close eyes tight, smile, whistle, puff cheeks
+
-
VIII. Vestibulo-cochlear
Hear watch ticking, hearing tests, balance tests
+
-
IX. Glossopharyngeal
Gag refl ex, ability to swallow
+
-
X.
Vagus
Gag refl ex, ability to swallow, say “Ahhh”
+
-
XI. Accessory
Resisted shoulder shrug
+
-
XII. Hypoglossal
Tongue protrusion (Observe for deviation)
+
-
Dizziness in Orthopaedic Physical Therapy Practice:
History and Physical Examination / 233
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