RU Physical Assessment of The Musculoskeletal System Question

History and Physical Assessment of the Musculoskeletal System

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Examiner:

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Date:

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Biographical Data:

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Patient: Age:

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Reason for visit:

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Health History (Subjective)

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• Any pain in the joints?
• Any stiffness in the joints?
• Any swelling/heat/redness in the joints?
• Any limitation of movement?
• Any muscle pain or cramping?
• Any deformity of bone or joint?
• Any accidents or trauma to bones or joints?
• Ever had back pain?
• Any problems with ADLs (activities of daily living)? Bathing, dressing, toileting, grooming, eating, mobility, or communicating?

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Physical Examination (Objective)

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• Cervical spine
  • Inspect size, contour, deformities
  • Palpate for temperature, pain, swelling, or mass
  • Active range of motion
• Shoulders
  • Inspect size, contour, deformities
  • Palpate for temperature, pain, swelling, or mass
  • Active range of motion
• Elbows
  • Inspect size, contour, deformities
  • Palpate for temperature, pain, swelling, or mass
  • Active range of motion
• Wrists and hands
  • Inspect size, contour, deformities
  • Palpate for temperature, pain, swelling, or mass
  • Active range of motion
• Hips
  • Inspect size, contour, deformities
  • Palpate for temperature, pain, swelling, or mass
  • Active range of motion
• Knees
  • Inspect size, contour, deformities
  • Palpate for temperature, pain, swelling, or mass
  • Active range of motion
• Ankles and feet
  • Inspect size, contour, deformities
  • Palpate for temperature, pain, swelling, or mass
  • Active range of motion
• Spine
  • Inspect for straight spinous processes
  • Inspect equal horizontal positions for shoulders, scapulae, iliac crests
  • Inspect for equal spaces between arms and lateral thorax
  • Inspect for knees and feet aligning with trunk, point forward
  • From side, note curvature: cervical, thoracic, lumbar
  • Palpate spinous processes
  • Active range of motion
• Functional Assessment
  • Walk (with shoes)
  • Perform KATZ ADL’s assessment
  • Perform Lawton IADL’s assessment
  • Pick up object from floor
  • Perform TUG test

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i.Flexion, extension, lateral bending right and left, right and left rotation

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i.Flexion, extension, abduction, adduction, internal rotation, external rotation

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i.Flexion, extension, supination, pronation

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i.Wrist extension, flexion

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ii.Finger estension, flexion

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iii.Ulnar deviation, radial deviation

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iv.Fingers spread, make fist

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v.Touch thumb to each finger

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i.Extension, flexion, external rotation, internal rotation, abduction, adduction

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i.Flexion, extension, walk

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i.Dorsiflexion, plantar flexion, inversion, eversion

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i.Flexion, extension, lateral bending left and right, rotation right and left

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Assessment Write-up

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Subjective Data

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Summarize your subjective data in narrative format with complete sentences.

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Objective Data

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Summarize your physical assessment findings here in narrative format with complete sentences. Be descriptive and include each part of the assessment. Include scores of functional assessments.

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Risk Factors and Plan

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Identify two risk factors for your patient from your assessment above. Tell me why you chose them and why they are significant. Then come up with a plan for improvement for your patient. This can just be a couple sentences.