Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino delas Alas Campus
Indang, Cavite

DOCUMENTATION: Musculoskeletal Assessment

SUBJECTIVE DATA:

The client confirmed with no musculoskeletal disease. No history of bone surgery. The
client had occasional back pain and stiff neck, thus using ibuprofen to alleviate the pain. The
client stated that he rarely feel tired and have enough energy to last a day. With normal joint
motion and no history of sprain and strain.

OBJECTIVE DATA:
 Gait: Posture is normal. Gait is steady with normal steps, base, arm swing, and
turning. Heel and toe walking are normal. Tandem gait is normal when the patient closes
one of her eyes.

 Joint: sternoclavicular and Temporomandibular join are with in full range of motion. No
tenderness and no clicking noise.

 Spine: Flexion, extension, and side-to-side rotation of cervical spine causes no

discomfort. Flexion, extension, and rotation of the remaining spinal column are within
normal limits. Patient can flex forward and reach toes with minimal pain.

 Shoulder: Both shoulders are symmetrical and uniform in color. 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.

 Elbow: No bony deformities, inflammation, or tenderness in olecranon, medial, lateral

epicondyle elbow. Full ROM upon flexion and extension. Elbow breadth: 7.2cm; Elbow
breadth: 2-7/8in; Height: 165cm.

 Wrist: 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.

 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 bulges and ballotment Tests. No effusion,
bulge/balloon sign.

 Ankles and feet: No bony deformities, inflammation, or tenderness in bony

prominences or soft tissue of foot or ankle. Full ROM dorsi/plantar flexion, inversion &
eversion. Warm to touch. No nodules palpated.

NAME: John Lloyd B. Agasang

Course/Section: BSN 2-3
 ASSESSMENT
HISTORY
Musculoskeletal none
disease
Bone surgery none
Medication Ibuprofen.
Pain Occasional back pain
stiffness Occasional stiff neck
Fatigue None
Joint instability None
Injuries none
PHYSICAL FINDINGS
Gait normal
Temporomandibular joint
ROM normal
Noise None
Tenderness None
Sternoclavicular joint
Location
Color Uniform
Swelling None
Masses None
Spine
Pain None
Tenderness None
ROM Normal
Shoulder
Symmetry Symmetrical
Color Even
Swelling None
Masses None
ROM normal
Elbow
Size Elbow breadth: 2-7/8in
Height: 165cm
Elbow breadth: 7.2cm

NAME: John Lloyd B. Agasang

Course/Section: BSN 2-3
 Shape Normal
Deformities None
Swelling None
ROM normal
Wrists
Size 7.5in
Symmetry Symmetrical
Color Uniform with arms
Swelling None
Tenderness None
Nodules None
ROM Normal
Carpal tunnel negative
syndrome
Hands and fingers
Symmetry Symmetrical
Swelling None
Color Uniform
Tenderness None
Nodules None
ROM Normal
Hips
Shape Normal
Symmetry Symmetrical
Knees
Deformities None
Pain None
Alignment Normal
Bulges test Negative
Ballotment test Negative
ROM Normal
Ankles and feet
Position Normal
Alignment Normal
Shape Normal
Skin Normal
Tenderness None

NAME: John Lloyd B. Agasang

Course/Section: BSN 2-3
 Temperature Even for both L & R
Swelling None
Nodules None
ROM normal

NAME: John Lloyd B. Agasang

Course/Section: BSN 2-3