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Surgery

The document is an evaluation performa for assessing general surgical conditions in patients at Jaipur National University’s Department of Physiotherapy. It includes sections for patient information, clinical diagnosis, pain symptoms, medical history, observations, examinations, exercise tolerance tests, muscle strength assessments, gait analysis, and treatment plans. The form is structured to facilitate comprehensive evaluation and documentation of the patient's condition and therapeutic needs.

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Rishabh Parashar
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11 views3 pages

Surgery

The document is an evaluation performa for assessing general surgical conditions in patients at Jaipur National University’s Department of Physiotherapy. It includes sections for patient information, clinical diagnosis, pain symptoms, medical history, observations, examinations, exercise tolerance tests, muscle strength assessments, gait analysis, and treatment plans. The form is structured to facilitate comprehensive evaluation and documentation of the patient's condition and therapeutic needs.

Uploaded by

Rishabh Parashar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Jaipur National University

Department of Physiotherapy
Evaluation Performa for General Surgical Conditions

Patient Name Gender/Age


Address Evaluation Date
Phone No. IPD Reg. No.
Occupation Name Of therapist

Clinical Diagnosis : ___________________________________________________________________________

Surgery : ___________________________________________________________________________________

Chief Complaints : ____________________________________________________________________________

History Of Present Illness :

Pain Symptoms :

1. Onset of Symptoms Gradual Sudden If sudden, was there a specific event/injury?


2. Pain Level Current Pain ____/10 Worst Pain ___/10
3. Pain Type Aching Dull Tingling Stabbing Burning Nauseating Other:
4. Pain Location
5. What relieves Pain/Symptom?
6. What Makes Pain/ Symptoms Worse ?

Dyspnea : ______________________________________________________________________________________

Cough : _______________________________________________________________________________________

Any Other : ____________________________________________________________________________________

Past Medical/ Surgical history :____________________________________________________________________

Smoking History : _______________________________________________________________________________

On Observation :
Posture : ______________________________________________________________________________________

Inspection Of Chest : ____________________________________________________________________________


SCAR Location length Extent Healing/Non healing Tenderness
Examination

Adherence Gaping Discharge : If Yes, Color Smell

Wound Location Extent Healing/Non healing Discharge – Yes/No


Examination Color Smell

Granulation Tissue Floor Edges Margin Bed

O/Palpation

Chest Excursion

Chest Expansion

O/Percussion

O/Auscultation

Musculoskeletal Evaluation :
Joint Movement Active Passive End Feel Tightness (With Grade)

Exercise Tolerance Test ( 6 Minute Walk Test )

Basal Parameters Post Recovery


1 min 3 min 6 min 9 min
BP
PR
RR
RPE
SPO2
Total Distance Walked :

• Muscle Strength
Muscle Group Right Left
Flexors
Extensors
Shoulder / Hip
Abductors
Adductors
Medial Rotators
Lateral Rotators
Elbow / Knee Flexors
Extensors
Flexors
Extensors
Wrist / Ankle Supinator’s / Pronators
Invertors / Evertors
Grip Power
Precision

Gait : ______________________________________________________________________________________

Investigations : ______________________________________________________________________________

Treatment Plan : ____________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Signature :

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