|
General: Well–developed well–nourished___
|
General abnormal findings
|
|
Skin
|
Skin
• • •
|
|
Skin abnormal findings
|
|
|
HEENT
|
HEENT
• • •
|
|
HEENT abnormal findings
|
|
|
Neck
|
Neck
• • •
|
|
Neck abnormal findings
|
|
|
Heart
|
Heart
• • •
|
|
Heart abnormal findings
|
|
|
Chest
|
Chest
• • •
|
|
Chest abnormal findings
|
|
|
Abdomen
|
Abdomen
• • •
|
|
Abdomen abnormal findings
|
|
|
Extremities
|
Extremities
• • •
|
|
Extremities abnormal findings
|
|
|
Neuromusculoskeletal Examination:
|
|
|
Appearance
|
Comments
|
|
Palpation
|
right/left/R>L/L>R/bilateral
• • •
|
|
paracervical/ trapezius/rhomboid
• • •
|
musculature with spasm/trigger points
|
|
Range of Motion of the Cervical Spine (AMA Guide
|
|
|
Forward Flexion: #/50
|
w/mild pain/w/pain
|
|
Right Lateral Flexion: : #/45
|
w/mild pain/w/pain
|
|
Right Rotation: #/80
|
w/mild pain/w/pain
|
|
Extension: #/60
|
w/mild pain/w/pain
|
|
Left Lateral Flexion: #/45
|
w/mild pain/w/pain
|
|
Left Rotation: #/80
|
w/mild pain/w/pain
|
|
Neurological level:
|
|
|
Dermatome (Sensory)
|
|
|
C5 through C8 is normal
|
Free text, if it is abnormal
|
|
Myotome (Motor)
|
|
|
C5 through C8 is normal
|
Free text, if it is abnormal
|
|
DTRs
|
|
|
Bicep (C5), Brachioradialis (C6), Tricep (C7)
|
Free text, if it is abnormal
|
|
Cervical distraction test
|
Cervical maximum compression test:
• • •
|
|
|
|
|
Examination of the Lumbar Spine, Pelvis and Hips
|
|
|
Appearance
|
Comments
|
|
Palpation
|
right/left/R>L/L>R/bilateral
• • •
|
|
paracervical/ trapezius/rhomboid
• • •
|
musculature with spasm/trigger points
|
|
Range of Motion of the Lumbar Spine
|
|
|
Forward Flexion: #/90
|
w/mild pain/w/pain
|
|
Right Lateral Flexion: : #/25
|
w/mild pain/w/pain
|
|
Extension: #/35
|
w/mild pain/w/pain
|
|
Left Lateral Flexion: #/25
|
w/mild pain/w/pain
|
|
Neurological level:
|
|
|
Dermatome
|
|
|
L2 through S1 is normal
|
Free text, if it is abnormal
|
|
Myotome
|
|
|
L4 through S1 is normal
|
Free text, if it is abnormal
|
|
Single squat and rise (L4):
|
Heel walk (L5):
|
|
Toe walk (S1):
|
|
|
DTRs
|
|
|
Patella (L4)
|
|
|
R
|
L
|
|
Achilles (S1)
|
|
|
R
|
L
|
|
Babinski (for UMN lesion)
|
Minor’s sign
|
|
ROM of the Hips
|
|
|
SLR
|
|
|
Right (-), arc to # degrees
|
with/without
|
|
_____posterior thigh pain
|
|
|
Left (-), arc to # degrees
|
with/without
|
|
_____posterior thigh pain
|
|
|
Note
|
Vasalva’s sign (for nerve root irritation):
|
|
Trendelenberg’s test (-) RT (-) LT
|
Trendelenberg’s test (for gluteus med weakness):
|
|
Yeoman’s test (for S-I pathology): (-) RT (-)LT
|
Yeoman’s test (for S-I pathology):
|
|
Patrick’s test (-)RT (-)LT
|
Patrick’s test (for iliopsoas contracture):
|
|
Patrick’s test (for hip pathology): (-) RT (-)LT
|
Patrick’s test (for hip pathology):
|
|
Gaenslen’s test (for S-I pathology): (-) RT(-)LT
|
Gaenslen’s test (for S-I pathology):
|
|
Kemp’s test (-)RT (-)LT
|
Kemp’s test (for intervertebral disc lesion):
|
|
|
|
|
DIAGNOSTIC DATA:
|
not available at this time
|
|
see attached
|
|
|
MRI lumbar spine
|
Date
|
|
MRI cervical spine
|
Date
|
|
MRI right/left shoulder
|
Date
|
|
MRI right/left knee
|
Date
|
|
UE EMG/NCV
|
Date
|
|
LE EMG/NCV
|
Date
|
|
X-ray lumbar spine
|
Date
|
|
Xray cervical spine
|
Date
|
|
Xray thoracic spine
|
Date
|
|
Any other X-rays
|
|
|
|
|
|
General WNL
|
General Abnormal
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT Comments
|
|
|
Skin WNL
|
Skin Lesion
|
|
Skin Comments
|
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
Neck Comments
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Abdomen Comments
|
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
MSK Comments
|
|
|
Breasts WNL
|
Breasts Abnormal
• • •
|
|
Breasts Comments
|
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Extrem Comments
|
|
