STATUS CERVICAL/SHOULDER PROBLEM

I. Identity
II. Anamnesis
 Chief complain
 History of present illness
o Pain (SOCRATES : site, onset, character, radiation, association, time course,
exacerbating/relieving factor, severity)
o Stiffness of the shoulder
o Crepitation of the shoulder while moving
o Weakness of the upper ext
o Numbness/tingling sensation
o Activity limitation associated with the shoulder pain (overhead activity)
 History of past illness
o Trauma
o HT, heart problem (utk exercise), DM, stroke, malignancy (ca mammae)
 Social economic & occupation
III. Physical Examination
a. Status General :
 VS
 BB, TB, BMI
 Posture, gait
b. Status Muskuloskeletal
 ROM ( bila ada stiffness evaluasi end feel : soft = soft tissue, firm =
muscle/ligament/kapsul, hard = bony block, empty = no end feel ex caused by pain)
 MMT
 MMT C5-T1
c. Status Local Cervical/Shoulder
 Inspection :
o Deformity
o Redness or swelling
o Atrophy (rotator cuff, supraspin, biceps)
o Neck posture : foward neck posture
o Shoulder assymetry
 Palpation :
o Warmth
o Location of tender point
o Crepitation
o Spasme paracervical, trapezius
 Special Test
o Cervical :
 Compression
  Distraction
 Spurling
 TOS I, II, III
o Shoulder Stability : apprehension (subluksasi)
o Impingement test :
 Neer
 Hawkin
o Rotator cuff :
 Empty Can (Suprasinatus tendinitis)
 Infraspinatus test (tendinitis infraspin)
 Lift off (tendinitis subscapularis)
o Tendinitis bicipitalis or instability bicipital groove :
 Yergason
 Speed
o Drop arm (Tear supraspinatus)
o Painfull arch
o Simultaneous ROM : apley scratch test
IV. Neurologial Examination
 Cranial nerve :
 Tonus / spasticity :
 DTR :
 Pathological Ref :
 Sensory : dermatom C5-T1

V. Barthel Index