Muscoloskeletal write up
• Write-Up: • This type of objective data only is required for the following videos: Musculoskeletal Exam Videos.
• The student should use the Body System Exam rubric as a guide and only document their physical exam findings.
(All findings are normal) Pt ID: MD 40 years of age, Female , Hispanic. No Complaints. •
The student should use medical terminology when documenting the examination findings in the objective section and be specific in documenting each rubric item assessed on video.
This is not a long narrative transcript of the video. • Please use headers and bullet points for organization.
• The student should follow APA format with a title page. No references are used in a write-up as this is the student’s own physical examination.
Dear Writter, this is the rubric of the procedures I did on the video I performed for your guidance:
HANDS Inspection:Swelling, deformity, redness, muscular atrophy, nodules, & joint symmetry Palpation: â¦Distal & proximal interphalangeal â¦Metacarpophalangeal ROM: Ability to make fist (tests function) â¦Flex and extend fingers of both hands also abduct and adduct fingers both hands.
WRISTS Inspection: Swelling, deformity, redness, atrophy, nodules, & joint symmetry Palpation: Palpate wrists including metacarpals and carpal bones of wrists ROM:Flex wrist to 90° downward & Extend wrist to 90° upward. â¦Ulnar & radial deviation wrist (aka abduction and adduction) Tinel’s Sign:Hyperextend the wrist and tap the median nerve with your middle finger or reflex hammer. Look for Pain or parenthesis radiating down the palm into the index, middle, and lateral half of ring finger. Phalen’s test:Flex the wrist to 90° maintain it for 40-60 seconds: Look for pain/parenthesis in the median nerve distribution.
ELBOWS Inspection:Redness, swelling, nodules, joint symmetry Palpation:(Note swelling, nodules, pain): Extensor surface of ulna, olecranon process, press on the lateral and medial epicondyles looking for pain – indicate which area indicates golfer’s/baseball elbow vs tennis elbow. ROM: â¦Extension & flexion â¦Supinate & pronate each hand with arms extended.
SHOULDERS Inspection : â¦Bilaterally/Posterior/anteriorly: Swelling, deformity, redness, atrophy, nodules, joint symmetry Palpation:â¦Noting for Tenderness & Fluid Acromioclavicular joint, biceps groove, tubercle of humerus, coracoid process, subdeltoid bursa (verbalize correct areas of palpation. ROM: â¦Flex shoulder forward to 180° â¦Extend backward to 60° (arm straight behind) â¦With arms at sides, abduct arm to 90° (abduction) â¦Adduct shoulder across midline to 90°. â¦Place hands behind small of back (internal rotation to 90° â¦Place hands behind neck with elbows out to side external rotation to 90° â¦Empty can test for supraspinatus:
HEAD AND NECK Inspection:Deformities, abnormal posture Palpation:Place first two fingers of each hand in front of tragus of ear and have patient open and close mouth (assessing TMJ tenderness) · Palpate sternoclavicular, cervical spine, paracervical muscles, trapezius muscles, rhomboids ROM: â¦Flexion –(Touch chin to chest), extension (put head back) Rotation: (rotate neck) side to side. â¦Open and close mouth; assess degree of maximal opening (patient should be able to place 3 of their own vertically placed fingers in mouth)OM: Lateral movement:Touch ear to corresponding shoulder, each side. ROM: â¦Lateral Movement with mouth open (move jaw side/side. â¦Spurling’s test (Cervical Compression test)for cervical radicular pain or paresthesia. Avoid this test on elderly/frail individuals or patients with serious spine disease or injury.
120°. â¦Valgus stress(With the knee slightly flexed to approx. 200 place outer hand on the lateral side of knee, grasp the medial foot or ankle with the opposite hand, and abduct the lower leg. â¦Varus stress: With the knee slightly flexed to approx. 20°, place the inner hand on the medial side of the knee, grasp the foot or ankle with the opposite hand, and adduct the lower leg. Lachman’s test:Flex knee slightly to about 20° and one hand stabilizes the lower femur while the other holds the tibia above the tibial tuberosity and then pulls and pushes the tibia to assess laxity of anterior and posterior cruciate ligaments. Drawer test:Patient is supine, knee flexed about 90°, examiner sits on patient’s foot, grabs upper leg, and pulls it anteriorly and posteriorly to assess for laxity of the respective cruciate ligaments. When done properly Lachman’s test is more sensitive. McMurry’s Test.Medially rotate the tibia and extend the knee- looking for laxity, pain, or crepitus.
HIPS Inspection:Swelling, nodules, redness, alignment (Start patient supine with legs straight together. Examiner begins standing to right of examination table and then moves to the left) Palpation:Anterior superior iliac spine (ASIS), greater trochanter, Posterior superior iliac spine, sacroiliac joint ROM: â¦Flex knee to 45°, externally and internally rotate each leg then return to original position. â¦Active & passive flexion of hip â¦Active & passive extension of hip â¦Abduction of hip to 60° bilateral â¦Adduction of hip to 30° bilateral Thomas test (to detect occult hip flexion contracture): Have patient flex right knee and pull firmly against abdomen. This flattens the normal lumbar lordosis. FABER aka Patrick’s test(flexion, abduction, external rotation of hip) to test for hip or sacroiliac joint disease. Place patient’s left foot on the right distal quadriceps just above the patella. Gently but firmly press the left knee to the exam table. SPINE Inspection :Pt standing:Cervical or lumbar lordosis or dorsal kyphosis (from side) â¦Shoulder height symmetry & iliac crest symmetry â¦Skin creases below buttocks – symmetrical (verbalize, do not video) Inspection –Scoliosis check (Patient bends slowly forward as far as possible with back to examiner): Check symmetry of movement, shoulder height, hip height, curve of spine Palpation:Spinous processes, intervertebral spaces Percuss spine: Using ulnar surface of fist! ROM Active: Bend to the right & left (lateral bending, 35°) â¦Forward bend 90° â¦Bend back towards examiner (extension, 35°) â¦Twist shoulders to right & left (rotation, 30°) Specialty Tests:Straight leg raises.
FEET AND TOES Inspection: â¦Flat feet (ples planus) – Observe (best while standing) Palpation: â¦Interdigital Neuroma (Morton’s Neuroma) and plantar fasciitis. â¦Distal & proximal interphalangeal & metatarsals ROM: â¦Flex (curl) toes & extend toes. â¦Invert foot & evert foot. ANKLES Inspection:Swelling, deformity, nodules, discoloration Palpation:Of medial/lateral malleolus & Achilles (gastrocnemius): Nodules, tenderness ROM:Examiner must test both active and passive here) Dorsiflex + plantar flex the ankle, rotate ankle in circles. KNEES Inspection: â¦Swelling, nodules, redness, alignment – valgus or varus deformity Palpation: â¦Suprapatellar pouch, sides of patella, popliteal fossa for Baker’s cyst ROM:â¦(Passive and active):Extend knee to 0° (leg straight out) & flex knee to at least
