anotherMUSCULOSKELTAL WRITE­UP

Cervical & Lumbar Spine

Inspection: Neck and spine have no noted deformities or signs of inflammation.
Curvature of cervical, thoracic, and lumbar spine are within normal limits. Bony features
of shoulders and hips are of equal height bilaterally. Posture is upright.
Palpation: Spinous processes of C7-L5 palpable, midline, and non-tender. Back
muscles are tight and tender between shoulder blades (rhomboids).
Range of motion (ROM): Flexion, extension, and side-to-side rotation of cervical
spine causes no discomfort. Flexion, extension, and rotation of the remaining spinal
column is within normal limits. Patient can flex forward and reach toes with minimal
pain. Lateral bending causes no discomfort (at rhomboids) when bending to the right and
left side.

Wrist, Hand, & Fingers

Right/Left hand dominant. No bony deformities, inflammation, or tenderness of bony
prominences. No anatomical snuff box tenderness; Full ROM in DIP, PIP, MCP, & carpal
joints & with supination and pronation. Right wrist was unable to extend fully. Phalen’s
& Tinel’s tests were negative.

Elbow
No bony deformities, inflammation, or tenderness in olecranon, medial, lateral
epicondyle elbow. Full ROM upon flexion and extension. Cubital tunnel (Tinel’s),
maneuver was negative.

Shoulder
No bony deformities, inflammation, or tenderness in rotator cuff, biceps tendon, or
acromioclavicular joint. Full ROM and strength in shoulder upon adduction, abduction,
internal and external rotation.

Hip
No bony deformities, inflammation, or tenderness in hip joint. Normal ROM upon
flexion & extension, internal & external rotation, abduction, & adduction. Full strength in
hip flexors/extensors, adductors/abductors.

Knee
No bony deformities, inflammation, or tenderness in bony prominences or soft tissue.
Full ROM (extension/flexion). Limited internal and external rotation. Medial, lateral
meniscus; anterior, posterior cruciate ligaments ,medial & lateral collateral ligaments
intact as assessed with negative Anterior/Posterior Drawer signs, Lachman’s, and
McMurray’s Tests. No effusion, bulge/balloon sign.

Foot, Ankle, & Toes

No bony deformities, inflammation, or tenderness in bony prominences or soft tissue of
foot or ankle. Full ROM dorsi/plantar flexion, inversion & eversion.

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