Preparation:

1. Assist the patient in a comfortable position.

2. Be clear in your instruction to the patient if you are asking the patient to
perform a certain body movement or to assume a certain position.
Demonstrate the desired movement if necessary.
3. Notify the patient before touching or manipulating a certain body part.
4. Inspection, palpation, ROM and muscle testing are performed on the major
skeletal muscles and joints of the body in cephalocaudal, proximal to distal
manner.
5. Examine non-affected parts before examining an affected area.
6. Avoid unnecessary or excessive manipulation of body parts.

Subjective Data:
History of Present Illness

Question
Have you had any recent weight gain?
Describe any difficulty that you have chewing.
Is it associated with tenderness or pain?
Describe any joint, muscle, or bone pain you have.
Where is the pain?
What does the pain feel like?
When did the pain start?
When does it occur?
How long does it last?
Any stiffness, swelling, limitation or movement?
Personal Health History
Describe any past problems or injuries you have
had to your joints, muscles, or bones.
What treatment was given?
Do you have any aftereffects from the injury or
problem?
When were your last tetanus immunizations?
Have you ever been diagnosed with DM, sickle cell
anemia, systemic lupus erythematosus, or
osteoporosis?
Rationale
Weight gain can increase physical stress and strain
on the musculoskeletal system.
Clients with TMJ dysfunction may have difficulty
chewing and may describe their jaws as “getting
locked or stuck.” Jaw tenderness, pain, or a clicking
sound may also be present with TMJ.
Bone pain is often dull, deep, and throbbing. Joint
or muscle pain is described as aching, but has been
differentiated between mechanical- and
inflammatory-type pains. Sharp, knife-life pain
occurs with most fractures and increases with
motion of the affected body part. Motion increases
pain associated with many joint problems but
decreases pain associated with rheumatoid arthritis
This information provides baseline data for the PE.
Past injuries may affect the client’s current ROM
and level of function in affected joints and
extremities. A history of recurrent fractures should
raise the question of possible physical abuse.
Joint stiffening and other musculoskeletal
symptoms may be a transient effect of the tetanus,
whooping cough, diphtheria, or polio vaccines.
Having these diseases places the client at risk for
development of musculoskeletal problems. Clients
who are immobile or have a reduced intake of

For middle-aged women:
Have you started menopause?
Are you receiving estrogen replacement therapy?
Family History
Do you have a family history of rheumatoid arthritis,
gout, or osteoporosis?
Lifestyle & Health Practices
What activities do you engage in to promote the
health of your muscles and bones (exercise, diet,
weight reduction)?
What medications are you taking?
Do you smoke tobacco? How much and how often?
Do you drink alcohol or caffeinated beverages?
How much and how often?
Describe the typical 24-hour diet? Are you able to
consume milk or milk-containing products? Do you
take any calcium supplements?
Describe your activities during a typical day. How
much time do you spend in the sunlight?
Describe any routine exercise that you do?
Describe your occupation.
Describe your posture at work and at leisure. What
type of shoes do you usually wear?
calcium and vitamin D are especially prone to
development of osteoporosis.
Women who begin menarche late or begin
menopause early are at greater risk for
development of osteoporosis because of decreased
estrogen levels, which tend to decrease the density
of bone mass.
These conditions tend to be familial and can
increase the client’s risk for development of these
diseases.
This question provides the examiner with
knowledge of how much the client understands and
actively participates in trying to promote the health
of the musculoskeletal system.
Some medications can affect musculoskeletal
function.
Smoking increases the risk of osteoporosis.
Excessive consumption of alcohol or caffeine can
increase the risk of osteoporosis.
Adequate protein in the diet promotes muscle tone
and bone growth; vitamin C promotes healing of
tissues and bones. A calcium deficiency increases
the risk of osteoporosis. A diet high in purine can
trigger gouty arthritis.
A sedentary lifestyle increases the risk of
osteoporosis. Prolonged immobility leads to muscle
atrophy. Exposure to 20 minutes of sunlight per day
promotes the production of vitamin D in the body.
Regular exercise promotes flexibility, bone density,
and muscle tone and strength. Improper body
positioning in contact sports results in injury to the
bones, joints, or muscles.
Certain job-related activities increase the risk for
development of musculoskeletal problems.
Poor posture, prolonged forward bending (sitting) or
backward leaning, or long-term carrying of heavy
objects can result in back problems. Contracture of
the Achilles tendon can occur with prolonged use of
high-heeled shoes.
Do you have difficulty performing normal ADLs? Do
you use assistive devices to promote your mobility?
How have your musculoskeletal problems interfered
with your ability to interact or socialize with others?
Have they interfered with your usual sexual activity?
How did you view yourself before you had this
musculoskeletal problem, and how do you view
yourself now?
Has your musculoskeletal problem added stress to
your life? Describe.
Have you ever had a bone density screening?
When was your last one?
Impairment of the musculoskeletal system may
impair the client’s ability to perform normal ADLs.
Musculoskeletal problems, especially chronic ones,
can disable and cripple the client, which may impair
socialization and prevent the client from performing
the same roles as in the past. Back problems, joint
pain, or muscle stiffness may interfere with sexual
activities.
Body image disturbances and chronic low
self-esteem may occur with a disabling or crippling
problem.
Musculoskeletal problems can greatly affect ADL
and role performance, resulting in changed
relationships and increased stress.
The U.S. Preventive Services Task Force
recommends that women younger than 60 get bone
density scans if they have risk factors for
osteoporosis including a history of fractured bones,
being Caucasian, smoking, alcohol abuse, or a
slender frame.

Objective Data
● Be sure that the room is at a comfortable temperature and provide rest
periods as necessary.
● Provide adequate draping to avoid unnecessary exposure of the client yet
adequate visualization of the part being examined.
● Explain that you will ask the client frequently to change positions and to move
various body parts against resistance and gravity.
Physical Assessment
● Observe gait and posture.
● Inspect joints, muscles, and extremities for size, symmetry, and color.
● Palpate joints, muscles, and extremities for tenderness, edema, heat,
nodules, or crepitus.
● Test muscle strength and ROM of joints.
● Compare bilateral findings of joints and muscles.
● Perform special tests for carpal tunnel syndrome.

Inspection of GAIT

- Observe the client’s gait as the a. Instruct the patient to walk - Walking is initiated in one
client enters the room. normally across the room. smooth, rhythmic fashion.
- Assess for the risk of falling b. Ask the patient to walk on the - The patient remains erect and
backward in the older or toes and then on the heels of the balanced during all stages of gait.
handicapped client by performing feet. - The arms swing freely at the
the “nudge test.” Stand behind the side of the torso but in opposite
c. Ask the patient to walk by
client and put your arms around direction to the movement of the
placing one foot in front of the
the client while you gently nudge legs. OR
other, in
the sternum. - Prior to turning, the head and
a “heel-to-toe” fashion (tandem
walking) neck turn toward the intended
direction, followed by the rest of
d. Instruct the patient to walk the body.
forward, then backward.
- The patient should be able to
e. Instruct the patient to ambulate
transfer easily to various
forward a few steps with the eyes
positions.
closed.
f. Observe the patient during
transfer between the standing and
sitting position.

Inspection & Palpation of TMJ

- Inspect and palpate the TMJ. a. Stand in front of the patient. It is normal to hear or palpate a
Have the client sit; put your index b. Inspect the right and left click when the mouth opens. The
and middle fingers just anterior to temporomandibular joints (CN VII) mouth can open 3 – 6 cm with
the external ear opening. Ask the c. Palpate the temporomandibular ease. The lower jaw protrudes
client to open the mouth as widely joints: without deviating to the side and
as possible. * Place your index and middle moves 1 – 2 cm with lateral
fingers over the joint movement.
- Test ROM. Ask the client to open
the mouth and move the jaw * Ask the patient to open and
laterally against resistance. Next, close the mouth
as the client clenches the teeth, * Feel the depression into
feel for contraction of the temporal which your fingers move with an
and masseter muscles to test the open mouth.
integrity of CN V (trigeminal
nerve) * Note the smoothness with
which the mandible moves.
* Note any audible or palpable
click as the mouth opens.
d. Assess ROM. Ask the patient
to:
* Open the mouth as wide as
possible.
* Push out the lower jaw
* Move the jaw from side to
side
e. Palpate the strength of the
masseter and temporalis muscle s
as the patient clenches the teeth
(CN V).
 Inspection & Palpation of STERNOCLAVICULAR JOINT

With the client sitting, inspect the

sternoclavicular joint for location
in midline, color, swelling, and
masses. Then palpate for
tenderness or pain.

Inspection & Palpation of TMJ

- Observe the cervical, thoracic,

and lumbar curves from the side,
then from behind. Have the client
standing erect with the gown
positioned to allow an adequate
view of the spine. Observe for
symmetry noting differences in
height of the shoulders, iliac crest,
and buttock creases.
- Palpate the spinous processes
and the paravertebral muscles on
both sides of the spine for
tenderness or pain.
- Test ROM of the cervical spine
by asking the client to touch the
chin to the chest (flexion) and to
look up at the ceiling
(hyperextension).
- Test lateral bending. Ask the
client to touch each ear to the
shoulder on that side.
- Evaluate rotation. Ask the client
to turn the head to the right and
left.

Inspection & Palpation of ELBOWS

- Inspect elbows in both flexed

and extended positions.
- Ask the client to perform the
following movements to test
ROM, flexion, extension,
pronation, and supination.

Inspection & Palpation of WRISTS

- Inspect wrist size, shape,
symmetry, color, and swelling.
Then palpate for tenderness and
nodules.
- Ask the client to bend the wrist
down and back (flexion and
extension)
- Test for carpal tunnel syndrome.
Perform Phalen’s test. Ask the
client to rest elbows on a table
and place the backs of both
hands against each other while
flexing the wrist 90 degrees with
fingers pointed downward and
wrists dangling. Have the client
hold this position for 60 seconds.
- Perform test for Tinel’s sign. Use
your finger to percuss lightly over
the median nerve.
- Test for thumb weakness. Ask
the client to raise thumb up from
plane of the palm.
- Ask the client to stretch the
thumb so that its pad rests on the
pad of the little finger pad.

Inspection & Palpation of HANDS & FINGERS

- Inspect size, shape, symmetry,

swelling, and color. Assess the
metacarpophalangeal joints by
squeezing the hand from each
side between your thumb and
fingers.
- Ask the client to spread the
fingers apart (abduction), make a
fist (adduction), bend the fingers
down (flexion), and then up
(hyperextension), move the thumb
away from the fingers and then
touch the thumb to the base of the
small finger.

Inspection & Palpation of HIPS

- With the client standing, inspect

symmetry and shape of the hips.
With the client supine, ask the
client to:
- Raise extended leg
- Flex knee up to chest while
keeping other leg extended.
- Move extended leg away from
midline of body as far as possible
and then toward midline of body
as far as possible (abduction and
adduction)
- Bend knee and turn leg inward
(rotation) and then outward
(rotation)
- Ask the client to lie prone and lift
extended leg off table.
Alternatively, ask the client to
stand and swing extended leg
backward.

Inspection & Palpation of KNEES

- With the client supine then Test ROM. Ask the client to
sitting with knees dangling, - Bend each knee up (flexion)
inspect for size, shape, symmetry, toward buttocks or back.
swelling, deformities, and - Straighten the knee
alignment. (extension/hyperextension).
- Palpate for tenderness, warmth, - Walk normally.
consistency, and nodules. Begin
- Test for pain and injury.
palpation 10 cm above the
patella, using your fingers and
thumb to move downward toward
the knee.
- If you notice swelling, perform
the bulge test to determine if the
swelling is due to accumulation of
fluid or soft-tissue swelling. With
the client in supine position, use
the ball of your hand firmly to
stroke the medial side of the knee
upward, three to four times, to
displace any accumulated fluid.
Then press on the lateral side of
the knee and look for a bulge on
the medial side of the knee.

Inspection & Palpation of ANKLES & FEET

- Inspect position, alignment,

shape, and skin.
- Palpate the toes from the distal
end proximally, noting tenderness,
swelling, bony prominences,
nodules, or crepitus of each
interphalangeal joint.
- Assess the metatarsophalangeal
joints by squeezing the foot from
each side with your thumbs and
fingers. Palpate each metatarsal,
noting swelling or tenderness.
Palpate the plantar area (bottom)
of the foot, noting pain or swelling.
Test ROM