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THORACIC eval

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					                                                      THORACIC EVALUATION FORM
Patient Name                                                                                            Eval Date
Physician                                                                                               DOB
Therapist                                                                                               Next MD visit

PERSONAL DATA
          1. BP (sitting):                             2. Heart Rate:
      _________/__________                            __________bpm
                                      3. Resp. Rate
                                     ______ per min



Pt History of Pain/Symptoms
4.    Age:                                                                          5.   Occupation:
6.    Onset of Sx’s   Gradual                Sudden              If sudden, was there a specific event/injury?
7.    Pain Location 
8.     Pain Level                         Current pain      ____/10              Worst pain _____/10               Best pain   _____/10
9.     Pain Type   Aching                  Dull      Tingling          Stabbing         Burning       Nauseating     Other:
10.     Radiating pain   Yes                No          If yes, where to?
11.     What relieves pain/Sxs?
(postures, movements meds, modalities)
12. What makes pain/Sxs worse?
(postures,, movements, activities)
13. Does pain occurs with:  Inspiration                  Expiration           Both
14. Difficulty breathing?                Yes       No
15. Is the pain affected by coughing, sneezing, or straining?   Yes                     No
16. Is the condition                 Improving       Getting worse           Staying the same
17. Any paresthesia or abnormal sensation?                   Yes       No        If yes, where?
18. Any problems with digestion?                   Yes       No         If yes, what kind?
19. Any skin abnormalities in thorax area?                  Yes       No        If yes, what kind?
Other:

Patient’s Goals:



Observations
                      Round back                                           Hump back                                      Flat back
                        Kyphosis                                        Razorback spine                                Dowager’s hump
                      Funnel chest                                         Barrel chest                                  Pigeon chest
                    Forward head                                       Rounded shoulders                                   Scoliosis
20. Breathing pattern:
21. Quality of respiration:
22. Effort required to inhale/exhale:
23. Coughing/Noisy/Abnormal breathing patterns?:
  Thoracic AROM/PROM:                                              Reproduction of Symptoms:                              Shoulder ROM Screen
                         Flex                                                      (With overpressure)                                 L              R
            L                                    R                 Flexion _____________________                          Flex     ________ ________
        L                                                          Extension ___________________                          Ext      ________ ________
                                                                   R SB _______________________                           IR       ________ ________
                                                                   L SB _______________________                           ER       ________ ________
                                                                   R Rot ______________________                           ABD      ________ ________
                                                                   L Rot ______________________                           HADD     ________ ________

                                                                   Cervical ROM (i.e. full and pain-free)
                                                                   Flex_________________            Ext_________________
                                                                   R SB________________             L SB________________
                          Ext
                                                                   R Rot________________            L Rot________________


  Palpation/Soft Tissue Assessment:



  Thoracic Spring Testing (note if Normal, Hyper, or Hypo)
                Central              R Unilateral            L Unilateral              R Rib              L Rib             Cervical           Lumbar
  T1            _______              _______                 _______                   _______            _______           C1 _______         L1 _______
  T2            _______              _______                 _______                   _______            _______           C2 _______         L2 _______
  T3            _______              _______                 _______                   _______            _______           C3 _______         L3 _______
  T4            _______              _______                 _______                   _______            _______           C4 _______         L4 _______
  T5            _______              _______                 _______                   _______            _______           C5 _______         L5 _______
  T6            _______              _______                 _______                   _______            _______           C6 _______
  T7            _______              _______                 _______                   _______            _______           C7 _______
  T8            _______              _______                 _______                   _______            _______
  T9            _______              _______                 _______                   _______            _______
  T10           _______              _______                 _______                   _______            _______
  T11           _______              _______                 _______                   _______            _______
  T12           _______              _______                 _______                   _______            _______
  Scapulo-Humeral Rhythm:                                                Special Tests (Neurodynamic):
                                                                         Slump Test: _______________ T1 Nerve Root Stretch: ____________
                                                                         Kernig’s Sign: _____________ Ulnar Nerve Testing: _____________
                                                                         SLR: ____________________ Beevor Sign:____________________
                                                                         Other: ___________________

  Manual Muscle Tests                                                 Scapular Manual Muscle Tests                            Thoracic General Dermatomes:
  Finger ABD (T1) ___________________                                 Upper Trap: R________ L________                         • T1: Medial Forearm
  Abdominals _______________________                                  Middle Trap: R________ L________                        • T2: Medial Arm
  Paraspinals ________________________                                Lower Trap: R________ L________                         • T4-6: Pain around Nipple
                                                                                                                              • T7-T8: Pain in epigastriac area
  Neck Extensors ____________________                                 Rhomboids: R________ L________
                                                                                                                              • T9-T11: Pain in umbilical area
  Neck Lat Flexors ___________________                                Serratus Ant: R________ L________                       • T12: Pain in the groin

Thoracic Manipulation Indications:
  • Assymetric Thoracic/Rib motion restriction                                                   Use Clinical Judgement to determine if Manip is Indicated
    (passive & active)                                                                           (check which perfomed):
  • Point tenderness                                                                                     • Thoracic (wedge) Manip
  • Pain with inhalation                                                                                 • Rib (screw-home) Manipulation
  • Acute Complaints – not long standing                                                                 • Upper Thoracic Manipulation (Seated, hands behind neck)
  • Muscle guarding upon palpation                                                                   Audible Pop? • Yes • No
  • Shoulder girdle pain, but Shoulder ROM not limited                                               Symptoms Post-Manip? _______________________
  • No Rib or Thoracic Spine fracture                                                               ___________________________________________
  • No Manip Contraindications (Paget’s, RA, Osteomyelitis, CA,
  Ankylosing Spondylitis, Cord/Cauda Equina Syndrome, Vertebral Artery involved)
                                                                                                 ______________________________________________
                                                                                                  *If Manip performed, complete f/u Thoracic stretching
Cervicothoracic Manipulation for Neck Pain
  •   Symptoms <30 days                                Liklihood Manip Success:             CT Manip Performed? • Yes • No
  •   No symptoms distal to the shoulder               +5 or 6 = 100%                               (seated, hands behind neck)
  •   Looking up doesn’t aggravate symptoms            +4 = 93%                             Audible Pop? • Yes • No
  •   FABQ-PA <12                                      +3 = 86%                             Symptoms Post-Manip? ___________
  •   Diminished upper thoracic kyphosis               +2 = 71%                             _______________________________
  •   Cervical Extension ROM < 30º                     +1 = 58%


Other Possible Thoracic Issues:
  • Osteoporotic Wedge Fracture                      • Thoracic Outlet Sydrome (must have symptom recreation for positive test)
                                                             • Roos Test
  • Dowager’s Hump                                           • Adson Maneuver
  • Scheuermann’s Disease Kyphosis                           • Halstead Maneuver
                                                     • Scoliosis:    Convexity: ________ Levels: ____________________
  • Long Thoracic Nerve Palsy
  • Costochondritis: most common ages 10-21, no PT Rx        • T4 Syndrome: treat with T4 region mob/manip
  pain with deep breathing        •   yes   •   no           UE symptoms              • pain     •   parasthesia   •   none
  pain brought on by exercise     •   yes   •   no           Non-dermatomal distribution         •   yes           •   no
  chest pain (esp ribs 4-6)       •   yes   •   no           Lack of hard neuro signs            •   yes           •   no
  costochondral TTP               •   yes   •   no           Headaches                           •   yes           •   no




  ASSESSMENT:




  SHORT TERM GOALS:                                          LONG TERM GOALS:
  1.                                                         1.
  2.                                                         2.
  3.                                                         3.


  PLAN:




 Signature___________________________________________________________ Date__________________________