Physiotherapist-Vorlage
Lower Quadrant sports injury Ax
Eine professionelle Physiotherapist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Looking for a comprehensive way to document your physiotherapy assessments? This 'Lower Quadrant Sports Injury Ax' template is designed for physiotherapists to efficiently record patient information, from subjective assessments to treatment plans. It covers key areas like pain levels, aggravating factors, and objective findings, ensuring a thorough record of the patient's condition. This template, when used with Heidi, allows for quick and accurate note-taking, saving valuable time and improving the quality of your clinical documentation.
Vorlagenvorschau
Subjective Assessment:
Patient presents today with a 6-week history of left knee pain following a fall during a football match. The patient reports the pain is gradually improving with rest and ice. The mechanism of injury was a direct blow to the lateral aspect of the knee. The patient is currently able to weight bear but experiences pain with twisting movements.
HPC:
The patient reports a gradual onset of left knee pain following a fall. Initially, the pain was severe, but it has gradually improved over the past six weeks. The patient denies any specific incident that worsened the pain recently.
VAS:
4/10 at rest, 6/10 with activity.
Aggravated by:
Twisting movements, prolonged standing, and squatting.
Eased by:
Rest, ice, and elevation.
Mandatory questions:
Night/Constant/Bilateral Pain/Weight Loss: No night pain, no constant pain, no bilateral pain, no weight loss.
Increased sweating/Night sweats: Denies increased sweating or night sweats.
Power loss/Numbness/Pins & needles: No power loss, numbness, or pins and needles.
Prolonged steroids/Osteoporosis: Denies prolonged steroid use or history of osteoporosis.
Anti-coagulants: Not on any anti-coagulants.
Sleep Disturbance: Sleep is not disturbed.
Metal Implants: No metal implants.
Relevant Medical History:
Nil.
PMH:
Nil.
Patient valued outcomes (PVOs):
Patient aims to return to playing football and be able to squat pain-free.
Objective Assessment:
Posture: Normal alignment.
Gait: Antalgic gait on the left leg.
Back - Movements: Within normal limits.
Back - Palpation: No tenderness.
Quadrant: Negative.
SI Joints - Stork: Negative.
SI Joints - Squish: Negative.
Hip Joints: Within normal limits.
Flexibility: Reduced knee flexion.
Strength: Reduced quadriceps strength.
ASIS Fixed: Negative.
SLR (Straight Leg Raise): Negative.
Palpation: Tenderness over the lateral joint line.
Functional: Squatting limited by pain.
Alignment: Normal.
Knees: Mild effusion.
Feet: Normal.
Other:
No other findings.
IMPRESSION:
Suspected meniscal injury.
PLAN:
Advise on RICE protocol. Provide education on activity modification. Commence quadriceps strengthening exercises. Review in 2 weeks.
TREATMENT:
Manual therapy to reduce swelling. Education on correct squatting technique.
HEP (Home Exercise Programme):
Quadriceps strengthening exercises, hamstring stretches, and gentle range of motion exercises.
ADVICE:
Advised to avoid activities that aggravate the pain. Advised to use ice after activity. Advised to follow the home exercise program.
Next Day Plan:
Review the patient's progress and adjust the treatment plan as needed. Continue with the current treatment plan.
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