It is important to establish the ABC's or airway, breathing and circulation first. When you are done with an assessment it is crucial to document everything or else it never happened.
History
- Introduce yourself
- Get to know your patient
- Ask open-ended questions
- Key questions to ask are: the mechanism of injury (MOI), location of the injury, acute vs chronic
IME Tampa (2015) [Untitled Medical Examination] retrieved December 3, 2015 from http://www.tampaortho.com/wp-content/uploads/2012/06/independent-medical-examination1.jpg
Observation
- Deformity
- ROM
- Edema
- Ecchymosis
- Ambulatory gait or carrying position of injured body part
Palpation
- Boney and soft tissue
- Start at the uninjured area and move towards the injury site
- Crepitus
- Heat caused from the injury
Special test
- ROM and manual muscle testing
- Neurological testing
- Sensory testing
- Reflex