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Big 4 Normal
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Big 4 Ant
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Additional General exam findings
• • •
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Gait Distress
• • •
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No assistive devices
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Assistive devices and braces
• • •
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No significant changes noted.
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Much more comfortableYes / No more uncomfortable
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BMI
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New Short Text Field
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Cervical Exam Heading
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Cervical CSSD-r
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Cervical spine exam: brief
• • •
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Cervical spine findings other:
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Cervical spine examination: tenderness
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Cervical tenderness location:
• • •
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Neurovascular status of the upper extremities is grossly intact.
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Neurovascular status of the upper extremities is intact. Sensation to light touch is normal and symmetric through the dermatomes
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Other:
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Open cervical spine other fields
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Sensory exam header
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Sensation intact
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|
Upper extremity sensory exam brief
• • •
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Comments
|
|
For Complex Neurovascular Exam go to upper extremity NV exam
|
|
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Motor exam header
|
Motor function intact
|
|
Upper extremity RIGHT motor function exam
• • •
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Upper extremity LEFT motor function exam
• • •
|
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Atrophy
• • •
|
Comments
|
|
Reflexes header
|
Reflexes normal
|
|
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Comments
|
|
Thoracic Exam Heading
|
|
|
Thoracic spine tenderness
|
|
|
Thoracic spine tenderness
• • •
|
Thoracic findings other:
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|
|
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Lumbar Exam Heading
|
|
|
Lumbar SSD-R
|
Negative tension signs brief
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|
Lumbar ROM
|
Lumbar findings other:
|
|
Lumbar spine exam: brief
• • •
|
Lumbar tenderness location:
• • •
|
|
Lumbar spine examination: tenderness
|
Comments
|
|
For Complex Neurovascular Exam go to lower extremity NV exam
|
|
|
Open Lumbar spine other fields
|
|
|
Neurovascular status of the lower extremities is grossly intact.
|
|
|
Neurovascular status of the lower extremities is intact brief
|
|
|
Sensory exam header
|
Sensation intact
|
|
|
Comments
|
|
Motor exam header
|
Motor function intact
|
|
|
Comments
|
|
Lower extremity RIGHT motor function exam
• • •
|
Lower extremity LEFT motor function exam
• • •
|
|
Sitting straight leg raise right
|
Sitting straight leg raise left
|
|
Extension sign right
|
Extension sign left
|
|
Supine straight leg raise right
|
Supine straight leg raise left
|
|
Crossed straight leg raise right
|
Crossed straight leg raise left
|
|
Bow string sign right
|
Bow string sign left
|
|
FABER sign right
|
FABER sign left
|
|
Reflexes header
|
Reflexes normal
|
|
Atrophy
• • •
|
Comments
|
|
Right shoulder examination:
|
Right shoulder normal
|
|
RIGHT shoulder impingement:
|
RIGHT shoulder severe impingement:
|
|
Shoulder exam: brief
• • •
|
Right shoulder ROM:
• • •
|
|
Right shoulder impingement signs:
• • •
|
Crepitation:
|
|
Pain with range of motion:
|
Comments
|
|
|
|
|
Left shoulder examination:
|
Left shoulder normal
|
|
LEFT shoulder impingement:
|
LEFT shoulder severe impingement:
|
|
Shoulder exam: brief
• • •
|
Left shoulder ROM:
• • •
|
|
Left shoulder impingement signs
• • •
|
Crepitation:
|
|
Pain with range of motion:
|
New Short Text Field
|
|
Upper extremities pulses ok no edema
|
Lower extremities pulses ok no edema
|
|
Full Body Diagram
|
No other significant changes
|
