SPINE AND EXTREMITIES
Head
Temporomandibular joint (TMJ) has no swelling, no
tenderness. Patient was able to open, close, protrude and
retract his jaw.
Neck
No tenderness. Full range of motion.
Hands, wrists and fingers.
No swelling, no redness, no nodules, no deformities, no muscle
atrophy on the hand.
Pink nail beds, no clubbing, no nail plate abnormalities.
No swelling, no boginess, no bone enlargement, no tenderness
on DIP, PIP, MCP.
No swelling, no tenderness on radius and ulna, no ulnar and
radial deviation.
Full ROM in all joints.
Carpal tunnel Syndrome: Tinel’s Sign & Phalen’s test
Upper Arms
Both arms are symmetrical, no atrophy. No tenderness, no
swelling on medial epicondyle, lateral epicondyle and
olecranon process of the ulna. No nodules and no effusion. Full
ROM on bilateral elbows.
Shoulder joints
Both shoulder joints and scapula are symmetrical, no swelling,
no tenderness.
No deformity, no muscle atrophy or fasciculations.
Full ROM (abduction, adduction, flexion, extension, external
rotation of the shoulder joints)
Spine
C7 has no swelling no tenderness.
Spine is symmetrical, no swelling, no deformities.
Thoracolumbar spine: (stand)
No kyphosis, lordosis , and scoliosis.
Full ROM. (be at the side & stabilize pt. Forward and lateral
flexion, extension and rotation)
Hip joints and lower limbs: (supine)
No swelling, tenderness, misalignments or deformities.
Full range of motion: (R) (L) (extension, abduction, adduction,
internal rotation, external rotation)
Special tests:
Straight leg raising test – Disc herniation – look for pain
Hugh Owen Thomas test – lumbar lordosis – flex knee
Patrick’s test – FABER – figure four test
Gaenlen’s test – pressure on hanging leg, firm pressure on
flexed knee towards chest
Trendelenburg test – lift one leg
Anvil test – hypothenar, pain in the hip
Knee joints (supine)
Patella mobile, no dislocation and no effusion.
Bulge/Balloon sign
Drawer test – anterior cruciate ligament
Valgus stress test – medial collateral ligament
Varus stress test – lateral collateral ligament
Full ROM (extension, flexion)
Lower leg:
No tenderness. No deformities. (tibia, fibula, gastrocnemius,
soleus, Achilles tendon)
Simmonds’s test: rupture of AT. N: plantarlexion upon
squeezing the calfs
Ankle joints and feet:
Full ROM (dorsiflexion, plantarflexion, inversion and eversion)
Pedal, toes, cutaneous, abnormalities
NEUROLOGICAL
Cerebrum / Mental Status
Patient is conscious, coherent, can follow simple and complex
commands, can name and repeat sentences.
Well-oriented (time, place, person and date), can do simple
calculation, with intact memory (remote, immediate, recent),
exhibits, knows general information, good abstract thinking and
appropriate moral judgement.
Cranial Nerves
CN I: smell intact | NT
CN II: visual acuity intact, visual fields full, fundoscopy / | NT
CN II & III: (direct/consensual light reflex) both pupils are
equally round and reactive to direct and consensual light
stimuli, pupil constricts to about 2mm. | NT
CN III, IV & VI: extraocular muscle intact. (H-test| NT
CN V: temporal and masseter strength intact, corneal reflexes
present. | NT
Motor: (clench teeth while palpating temporal and masseter)
Sensory: Pain, sensation, light touch
Corneal reflex – CN V and 7
CN VII: intact / not tested
Motor: U: raise eyebrows, wrinkle forehead, close eyes tightly
L: smile/frown, purse lips, whistle, and blow the cheeks full.
Sensory: taste sensation – ant. 2/3
CN VIII: hearing intact bilaterally to whispered voice intact/ not
tested. Negative Weber and Rinne test / not tested
CN IX & X: uvula midline; gag reflex intact, normal pharyngeal
wall movement, no hoarseness noted or vocal anomalies
CN XI: strength of sternocleidomastoid and trapezius muscles
5/5; shrug shoulders equally; able to rotate head against
resistance;
CN XII: tongue is midline; no apparent deviation upon
protrusion and retrusion; no fasciculation or atrophy noted.
Motor Testing
(inspect) Muscles are symmetrical in both upper and lower
extremities, no atrophy, no fasciculations, no tremors.
Muscle tone is (spastic, rigid, hypotonic, normal)
Upper extremities:
Lower extremities:
0 — No muscular contraction detected; 1 — barely detectable contraction
2 — Active movement of the body part with gravity eliminated
3 — Active movement against gravity; 4 — Active movement against gravity and
some resistance; 5 — Active movement against full resistance without evident
fatigue. This is normal muscle strength.
Cerebellum
Rapid alternating movements (RAMs) (foot tapping, altermating
pronation and supination), finger-to-nose (F→N), heel-to-shin
(H→S) intact. Gait with normal base. (heel-to-toe-tandem
walking)
Romberg—maintains balance with eyes closed.
Reflexes
4 - hyperactive
3 – brisker than average
2 – normal
1 – low normal
0 – absent
Meningeal signs (Babinski test (A: Dorsiflexion of the big toe),
Kernig's and Brudzinsky sign)
Sensory Exam
Peripheral: Pain sensation (pinprick on same dermatomes),
Joint sense (up, down), Vibration sense (tuning fork on joint on
finger and toes - 4th digit), Romberg’s test
Central: Agnosia (Streognosis - key, ballpen, coin), point
localization, 2-point discrimination (paperclip)