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This document outlines a clinical reasoning form used by physiotherapists at SRI Ramachandra University to evaluate musculoskeletal patients. The form guides physiotherapists through gathering a patient history, identifying red flags, developing provisional hypotheses, conducting a physical exam, and creating a treatment plan. Key sections include assessing pain symptoms, potential neural involvement, irritability of the condition, predisposing factors, and formulating a hypothesis supported by exam findings. The goal is to systematically work through exam and diagnosis to establish the patient's problem and develop an appropriate treatment approach.

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Sri Hari
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148 views

CR Format

This document outlines a clinical reasoning form used by physiotherapists at SRI Ramachandra University to evaluate musculoskeletal patients. The form guides physiotherapists through gathering a patient history, identifying red flags, developing provisional hypotheses, conducting a physical exam, and creating a treatment plan. Key sections include assessing pain symptoms, potential neural involvement, irritability of the condition, predisposing factors, and formulating a hypothesis supported by exam findings. The goal is to systematically work through exam and diagnosis to establish the patient's problem and develop an appropriate treatment approach.

Uploaded by

Sri Hari
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SRI RAMACHANDRA UNIVERSITY

FACULTY OF PHYSIOTHERAPY

MUSCULOSKELETAL PHYSIOTHERAPY CLINICAL REASONING FORM


(How to evaluate and plan out the physical examination and treatment from the Interview and
History)

Part 1: History and Interview


1) After establishing the patient's symptomatic area (i.e. after completing the body chart), &
pain assessment, nominate structures to be considered as possible sources of their current
disorder.

2) Are there any red flag conditions that warrant referral? YES / NO

Specify?

Based on the above red flags, what action might you take?

3) Are there any yellow flags that may influence prognosis or response to treatment? YES / NO

Specify?

4) Are there any blue flags that may influence prognosis or response to treatment? YES / NO

Specify?

5) Is there possible involvement of the neural tissue? YES / NO

Specify? Compression, irritation, mobility/tension

Would you do a neurological exam (or a neural tissue mobility test?) YES / NO
Justify your reasoning:
6) Is the pain:

a) Severe/moderate/mild? (VAS rating?)


b) Latent? YES / NO

7) Does the history suggest an irritable disorder? YES / NO

a) Local symptoms YES / NO


b) Referred/other symptoms YES / NO

Justify your answers:


 Activity causing the pain (how quickly is it provoked?)
 Severity of pain caused
 Duration before pain subsides?

8) Does the “nature” of the disorder indicate caution? YES / NO

Specify:
a) Pathology/injury
b) Ease of exacerbation of acute pain

9) Are there any contraindications to any part of your physical examination? YES / NO

Specify:
10) Do you predict your physical examination to be:

a) Comprehensive
b) Comprehensive but ready to modify/limit
c) Selective due to severity or irritability of the symptoms?

11) Associated examination


Nominate any predisposing, contributing or reactive factors likely to be involved in this patient’s
condition.
Specify:
 Poor neuromotor control, lack of active stability
 Poor muscle endurance or strength
 Joint hypomobility, instability or hypermobility
 Proprioceptive deficit
 Postural issues
 Potential work, home or sporting ergonomic factors
 Any spinal deformity
 Any trauma
 Previous or existing pathology
 Any other conditions

12) What is your provisional hypothesis and what history / physical examination findings support
this?

13) Nominate any alternative hypotheses and the history / physical examination findings that would
support these.
Part 2: Planning your Physical Examination
 Clearly define what tests you will do to confirm or negate your hypotheses
 List the examination techniques which you would like to use to test your hypotheses
within the irritability of the patient’s condition.
 Bracket any tests that would not be a priority for your first assessment
 Remember to consider the time available for your assessment

After the physical examination

i) Nominate your main findings/problem listing (key asterisk* signs)

ii) Do they confirm your provisional diagnostic hypothesis? YES / NO

Justify your choice of hypothesis or revised hypothesis


Part 3: Treatment Plan

i) When would you like to see this patient again?

ii) Why have you chosen this time frame?

iii) Home exercise program (HEP) and advice?

iv) Your aims for the next assessment and treatment session

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