Lungs :

Inspection : symmetrical movement during inspiration

and expiration, suprasternal retraction
Palpation : stem fremitus symmetrical, intercostalis space
Wnl
symmetrical, chest expansion:
Percussion : sonor on both lungs
Auscultation : vesicular, no ronchi, no wheezing

Abdomen Flexible on palpation, liver/spleen : not palpable, no mass,

Wnl
  no tenderness, bowel sound positive normal
Vertebral alignment straight, shoulder and scapulae
Back symmetrical, no muscle spasm, no tenderness, no hump, Wnl
no skin erusion/decubitus

III.3. Neuromuscular Examination

Status Findings Impression

Consciousness Compos mentis (GCS: E4 M6 V5 = 15)  Wnl

Cranial nerves Normal Wnl
Movement Cervical: no pain Pain on right
Upper extremities: no pain knee
Trunk: no pain
Lower extremities: pain on right knee
Tonus Upper and lower extremities muscles : Normotonus Wnl
Trophy Upper extremity : Normotrophy Wnl
Lower extremity : Normotrophy
 MMT and ROM Listed below  
Physiological ++/++ for biceps/triceps Wnl
reflexes ++/++ for patella/achilles
Patological reflexes -/ - (Hoffman Trommer) Wnl
-/- (Babinski)
Clonus Upper extremities: -/- Wnl
Lower extremities: -/-
Sensibility Dermatom distribution Wnl
Upper extremity:
2-2-2-2-2/2-2-2-2-2 (C5-C6-C7-C8-T1)
Lower extremity:
2-2-2-2-2/2-2-2-2-2 (L2-L3-L4-L5-S1)
Proprioception Upper extremities: +/+ Wnl
Lower extremities: +/+

III.4. Musculoskeletal Examination

III.4.1. Cervical and Upper Extremity

Right Left
Look
Deformity (-) (-)
Inflammation sign (-) (-)
Atrophy (-) (-)
Edema (-) (-)
Feel
Spasm (-) (-)
Tenderness (-) (-)
Tone (-) (-)
Move
Pain - -
Rom (listed below) Full Full