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GENERAL
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General Examination
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General [-]
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General [+]
• • •
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General [Additional Comments]
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HEENT [-]
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HEENT [+]
• • •
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HEENT [Additional Comments]
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Cardiovascular [-]
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Cardiovascular [+]
• • •
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Cardiovascular [Additional Comments]
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Lungs [-]
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Lungs [+]
• • •
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Lungs [Additional Comments]
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Abdomen [-]
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Abdomen [+]
• • •
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Abdomen [Additional Comments]
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Extremities [-]
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Extremities [+]
• • •
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Extremities [Additional Comments]
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LUMBAR SPINE
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Lumbar Spine Examination
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Inspection [-]
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Inspection [+]
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Inspection [Additional Comments]
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Palpation [-]
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Palpation [+]
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Palpation -- General
• • •
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Palpation (R) -- Finding
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Palpation (R) -- Location
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Palpation (L) -- Finding
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Palpation (L) -- Location
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Palpation (Bilaterally) -- Finding
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Palpation (Bilaterally) -- Location
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Palpation [Additional Comments]
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Musculature [-]
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Musculature [+]
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Musculature (R) -- Finding
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Musculature (R) -- Location
• • •
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Musculature (L) -- Finding
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Musculature (L) -- Location
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Musculature (Bilaterally) -- Finding
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Musculature (Bilaterally) -- Location
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Dermatomes [-]
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Dermatomes [+]
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Dermatomes (R)
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Dermatomes (L)
• • •
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Sacrum [-]
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Sacrum [+]
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Sacrum (R)
• • •
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Sacrum (L)
• • •
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Sacroiliac Joint [-]
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Sacroiliac Joint [+]
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Sacroiliac Joint (R)
• • •
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Sacroiliac Joint (L)
• • •
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Coccyx [-]
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Coccyx [+]
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Coccyx (R)
• • •
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Coccyx (L)
• • •
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ROM Flexion
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ROM Extension
• • •
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ROM Rotation
• • •
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ROM Sidebending
• • •
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Knee Reflex
• • •
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Ankle Reflex
• • •
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EHL Strength
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FHL Strength
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Anterior Tibialis Strength
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Gastroc-Soleus Strength
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Hamstrings Strength
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Quadriceps Strength
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Muscle Strength -- Lower Extremities
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General Sensation [-]
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General Sensation [+]
• • •
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Foot Sensation
• • •
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Calf Sensation
• • •
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Anterior Thigh Sensation
• • •
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Lower Extremities -- Numbness, Tingling & Burning
• • •
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Sensation Comments
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Capillary Filling
• • •
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Gait
• • •
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Straight Leg Raise
• • •
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Patrick Test
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Patrick Test (Definition)
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Trendelenburg Sign
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Trendelenburg Sign (Definition)
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Milgram Test
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Milgram Test (Definition)
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Tandem Gait Test
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Tandem Gait Test (Definition)
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Previous Surgical Wounds
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Are previous surgical wounds fully healed?
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Previous Surgical Wounds -- Signs
• • •
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CERVICAL SPINE (NECK)
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Cervical Spine (Neck) Examination
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Inspection [-]
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Inspection [+]
• • •
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Inspection [Additional Comments]
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Palpation [-]
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Palpation [+]
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Palpation (R) -- Finding
• • •
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Palpation (R) -- Location
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Palpation (L) -- Finding
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Palpation (L) -- Location
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Palpation (Bilaterally) -- Finding
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Palpation (Bilaterally) -- Location
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Palpation [Additional Comments]
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Musculature [-]
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Musculature [+]
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Musculature (R) -- Finding
• • •
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Musculature (R) -- Location
• • •
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Musculature (L) -- Finding
• • •
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Musculature (L) -- Location
• • •
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Musculature (Bilaterally) -- Finding
• • •
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Musculature (Bilaterally) -- Location
• • •
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Dermatomes [-]
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Dermatomes [+]
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Dermatomes (R)
• • •
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Dermatomes (L)
• • •
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ROM Flexion
• • •
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ROM Extension
• • •
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ROM Rotation
• • •
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ROM Sidebending
• • •
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General Sensation [-]
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General Sensation [+]
• • •
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Upper Extremities -- Numbness, Tingling & Burning
• • •
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Biceps Reflex
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Biceps Reflex (R)
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Biceps Reflex (L)
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Triceps Reflex
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Triceps Reflex (R)
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Triceps Reflex (L)
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Brachioradialis Reflex
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Brachioradialis Reflex (R)
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Brachioradialis Reflex (L)
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Adson Test
• • •
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Adson Test [Definition]
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Compression Test
• • •
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Compression Test [Definition]
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Spurling Test
• • •
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Spurling Test [Definition]
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Previous Surgical Wounds
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Previous surgical wounds fully healed?
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Previous Surgical Wounds -- Signs
• • •
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HIP
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Hip Examination
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Pain [-]
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Pain [+]
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Pain (R)
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Pain (R) -- Movement
• • •
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Pain (L)
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Pain (L) -- Movement
• • •
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Tenderness [-]
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Tenderness [+]
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Tenderness (R)
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Tenderness (R) -- Location
• • •
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Tenderness (L)
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Tenderness (L) -- Location
• • •
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Sensation [-]
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Sensation [+]
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Sensation (R) -- Finding
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Sensation (R) -- Location
• • •
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Sensation (L) -- Finding
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Sensation (L) -- Location
• • •
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ROM Hips
• • •
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Hip Strength
• • •
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Gait
• • •
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Leg Lengths
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Are leg lengths equal?
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Leg Lengths Unequal -- Description
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Previous Surgical Wounds
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Previous Surgical Wounds -- Location
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Previous surgical wounds fully healed?
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Previous Surgical Wounds -- Signs
• • •
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KNEE
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Knee Examination
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Effusion [-]
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Effusion [+]
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Effusion (R)
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Effusion (R) -- Severity
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Effusion (L)
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Effusion (L) -- Severity
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Ecchymosis [-]
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Ecchymosis [+]
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Ecchymosis (R)
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Ecchymosis (R) -- Location
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Ecchymosis (L)
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Ecchymosis (L) -- Location
• • •
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Tenderness [-]
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Tenderness [+]
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Tenderness (R)
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Tenderness (R) -- Severity
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Tenderness (L)
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Tenderness (L) -- Severity
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Weakness
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Valgus Instability [-]
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Valgus Instability [+]
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Valgus Instability (R)
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Valgus Instability (R) -- Severity
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Valgus Instability (L)
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Valgus Instability (L) -- Severity
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Varus Instability [-]
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Varus Instability [+]
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Varus Instability (R)
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Varus Instability (R) -- Severity
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Varus Instability (L)
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Varus Instability (L) -- Severity
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Patellar Instability [-]
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Patellar Instability [+]
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Patellar Instability (R)
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Patellar Instability (R) -- Severity
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Patellar Instability (R) -- Direction
• • •
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Patellar Instability (L)
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Patellar Instability (L) -- Severity
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Patellar Instability (L) -- Direction
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ROM Flexion (N = 180)
• • •
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Quadriceps Strength
• • •
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Hamstrings Strength
• • •
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Lachman's Test [-]
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Lachman's Test [+]
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Lachman's Test (R) -- Positive
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Lachman's Test (R) -- End Point
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Lachman's Test (L) -- Positive
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Lachman's Test (L) -- End Point
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Posterior Drawer Test
• • •
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McMurray Test
• • •
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Patellar Tracking [-]
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Patellar Tracking [+]
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Patellar Tracking (R) -- Abnormal Motion
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Patellar Tracking (R) -- Direction of Abnormal Motion
• • •
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Patellar Tracking (L) -- Abnormal Motion
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Patellar Tracking (L) -- Direction of Abnormal Motion
• • •
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Calf Pain [-]
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Calf Pain [+]
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Calf Pain (R)
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Calf Pain (R) -- Severity
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Calf Pain (L)
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Calf Pain (L) -- Severity
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Calf Swelling [-]
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Calf Swelling [+]
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Calf Swelling (R)
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Calf Swelling (R) -- Severity
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Calf Swelling (L)
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Calf Swelling (L) -- Severity
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Sensation [-]
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Sensation [+]
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Sensation (R) -- Finding
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Sensation (R) -- Location
• • •
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Sensation (L) -- Finding
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Sensation (L) -- Location
• • •
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Gait
• • •
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Previous Surgical Wounds
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Previous Surgical Wounds -- Location
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Previous surgical wounds fully healed?
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Previous Surgical Wounds -- Signs
• • •
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SHOULDER
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Shoulder Examination
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Pain [-]
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Pain [+]
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Pain (R)
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Pain (R) -- Movement
• • •
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Pain (L)
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Pain (L) -- Movement
• • •
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Tenderness [-]
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Tenderness [+]
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Tenderness (R)
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Tenderness (R) -- Location
• • •
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Tenderness (L)
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Tenderness (L) -- Location
• • •
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Deformity [-]
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Deformity [+]
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Deformity (R)
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Deformity (R) -- Location
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Deformity (L)
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Deformity (L) -- Location
• • •
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Ecchymosis [-]
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Ecchymosis [+]
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Ecchymosis (R)
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Ecchymosis (R) -- Location
• • •
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Ecchymosis (L)
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Ecchymosis (L) -- Location
• • •
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Instability [-]
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Instability [+]
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Instability (R)
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Instability (R) -- Location
• • •
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Instability (L)
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Instability (L) -- Location
• • •
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Swelling [-]
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Swelling [+]
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Swelling (R)
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Swelling (R) -- Location
• • •
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Swelling (L)
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Swelling (L) -- Location
• • •
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Capillary Refill
• • •
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Rotator Cuff Strength
• • •
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Biceps Strength
• • •
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Triceps Strength
• • •
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Deltoid Strength
• • •
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ROM Flexion
• • •
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ROM Extension
• • •
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ROM Abduction
• • •
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ROM External Rotation
• • •
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ROM Internal Rotation
• • •
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Drop Arm Test
• • •
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Impingement Test
• • •
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Previous Surgical Wounds
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Previous Surgical Wounds -- Location
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Are previous surgical wounds fully healed?
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Previous Surgical Wounds -- Signs
• • •
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