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Subjective:
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Area of pain
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Location
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When did it start?
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Onset
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Mechanism of injury
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Comments
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Trauma?
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Frequency
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Progress
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Pallative:
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Provocative
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Timing
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Modifying factors:
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ADLs
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ADL comments
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Pain Quality
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VAS
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Denies Numbness/Tingling
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Numbness/Tingling Radiation
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Denies Radiation
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Radiation
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Radiation comments:
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Secondary Symptoms:
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Prenatal
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# of children
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Previous pregnancy complications:
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More information about previous pregnancies:
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Due Date:
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Describe pregnancy
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Pregnancy related symptoms:
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Additional information about pregnancy:
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Prenatal referrals:
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No other care before today.
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Providers seen for this symptom:
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No imaging
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Imaging
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Patient's imaging shows:
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Red flags (bowel, bladder, Valsalva)
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Family History
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Previous Medical and Surgical History:
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Trauma hx
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Profession/job:
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Daily Exercise
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Stress Level
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Medications / Supplements
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Additional notes
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Objective
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HEENT
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Observation:
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Gait
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C/S:
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Palpation:
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Trigger Points:
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Tender Facets
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Segmental Dysfunction
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Cervical ROM:
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Flexion
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Pain?
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Extension
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Pain?
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Right Rotation
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Pain?
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Left Rotation
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Pain?
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Right Lateral Flexion
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Pain?
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Left Lateral Flexion
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Pain?
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Cervical Spine Orthopedic Tests
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Spurling's / Max. Cervical Compression Test- ext w/ lateral flexion; ddx facet or NRC
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Jackson's- lateral flexion; ddx facet or NRC
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Cervical Distraction- ddx facet or NRC vs ligament or mm dysfunction
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Bakody's Test- C4 or C5 NRC
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Shoulder Depression Test- ddx facet or NRC
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O'Donoghue's Maneuver
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Adson's Test
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Vertebral Artery Insufficiency Test
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Flexion Compression Test- ddx posterolateral disc extrusion
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Extension Compression Test- decrease of s/s intact annulus; increase of s/s w/o radiculopathy DJD or facet
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Hoffman's Sign-Flick the nail of the middle finger, positive sign (flexion of the thumb and/or index finger) indicates a possible problem with the spinal cord or brain, MS
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L'hermitte's Sign-Positive- electrical shock down spine and into arms or legs; MS, spinal cord injury, cervical myelitis, or cervical spondylosis (can also be triggered by neck flexion, coughing, sneezing, yawning) Patient flexes head.
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Additional notes
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Advanced Cervical Tests
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Sharp Purser Test- for patients with RA, C1/C2 instability, clunk
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Rust Sign- patient holding head after trauma
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Alar Ligament Test- supine, practitioner contacts spinous of C2, passive lateral flexion, repeat with rotation; excessive motion (should be little motion and a capsular end feel)
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Cervical Neurological Exam
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Deep Tendon Reflexes:
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Sensation:
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Manual Muscle Testing:
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Additional notes
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T/S:
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Visual
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Palpation
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Tender Facets
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Intersegmental Dysfunction
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T/S ROM:
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Flexion
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Pain?
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Extension
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Pain?
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Rt Rotation
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Pain?
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Lt Rotation
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Pain?
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Rt Lateral Flexion
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Pain?
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Lt Lateral Flexion
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Pain?
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Thoracic Orthopedic Tests
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Adam's Sign
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Spinous Percussion
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Soto-Hall-supine, cx flexion while applying pressure to sternum, repeat w/legs raised 45 deg, pain/ electric shock; ddx tumor, spinal cord compression, lesion
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Slump Test- NRC, disc, TOS
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Heel Drop Test-pain lower right quadrant indicating possible appendicitis, possible compression fracture
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Additional notes
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Advanced Thoracic Tests
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Murphy's Punch- ddx kidney infection or stones
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Schepelmann's- pain on concavity is intercostal neuritis, pain on convexity is pleurisy
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Roo's/East- 3 min arm raised
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Kemp's Test:
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O'Donoghue's
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L/S:
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Palpation:
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Trigger Points:
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Tender Facets
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Intersegmental Dysfunction
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Lumbar ROM:
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Flexion
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Pain?
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Extension
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Pain?
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Rt. Rot
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Pain?
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Lt. Rot
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Pain?
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Rt. Lat. Flex
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Pain?
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Lt. Lat. Flex
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Pain?
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Pelvis
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Pelvis:
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Lumbar Spine Orthopedic Tests
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Trendelenburg-Positive- hip hike, pain indicating gluteus medius/minimus weakness indicated by a drop of the pelvis on the non-weight-bearing side
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Dejerines Triad
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Minors Sign
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SLR
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Kemp's Test
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Milgram's Test- pt holds legs off table 15-30 sec; reproduction of pain, indicating herniated disc or impinged lumbar nerve, or stenosis
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Slump Test
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Additional notes
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Advanced Lumbopelvic Tests
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Braggard's Test- dull posterior thigh pain is tight hamstrings; 0-35 degrees sciatica, 35-70 IVD
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Well Leg Raise (L4-S2)
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FABER/Patrick's Test- pain in hip, groin, buttock, limited ROM, clicking or popping indicating OA, hip impingement or labral tear, SI joint dysfunction; pain in the groin area during the test can suggest iliopsoas strain or bursitis
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Ely's Test/Sign:
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FADIR- pain in hip, groin, buttock, limited ROM, clicking or popping indicating hip impingement
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Scour- pain in hip, groin, buttock, limited ROM, clicking or popping indicating hip pathology
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Thomas Test- tight hip flexors
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Ober's Test- tight TFL/ITB
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Gaenslen's Test-supine, painful leg off table, opp side flexed to chest and held (Thomas Test), downward pressure from Dr. on affected leg; pain in SI joint indicating SI joint dysfunction, pubic symphysis instability, hip pathology, L4
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Hibb's Test- prone with knee flexed to 90°, practitioner internally rotates the hip by pulling the ankle laterally and while stabilizing the sacroiliac joint; pain indicating SI joint or ligament pathology
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Yeoman's Test-prone with knee flexed to buttock, then hip placed into passive extension; pain indicating SI joint dysfunction
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Iliac Compression Test
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Lumbar Neurological Tests
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Deep Tendon Reflexes:
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Sensation:
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Manual Muscle Testing:
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Additional notes
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Shoulder Exam
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Palpation:
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Passive ROM
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Active ROM
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Shoulder Manual Muscle Testing
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Flexion- deltoid, pectoralis major, coracobrachialis, biceps brachii
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Extension- posterior deltoid, latissimus dorsi, teres major
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Abduction- deltoid, supraspinatus (first 15 deg), trapezius
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Adduction- pectoralis major, latissiumus dorsi, teres major
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External rotation- infraspinatus, teres minor
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Internal rotation- subscapularis, pectoralis major, latissimus dorsi, teres major, anterior deltoid
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Shoulder Orthopedic Tests
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Speeds Test- biceps tendonitis, SLAP lesion, inflammation
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Codman's Drop Arm- full thickness rotator cuff tear; confirm w/infraspinatus test, painful arc
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Empty Can aka Jobe aka Supraspinatus Test- supraspinatus tendonitis or tear, neuropathy of suprascapular nerve
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Dawburns Test/ Apley Scratch- internal rotation and adduction, lack of mobility
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Yergason's Test- long head biceps
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Hawkin's Kennedy- subacromial impingement; pain during internal rotation, irritation of bursa
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Lift Off Test- subscapularis tear (cannot lift off back)
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Impingement Sign- rotator cuff tendonitis, confirm with Drop Arm and Hawkins Kennedy
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Sulcus Sign- GH instability, possible tears, subluxation
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Posterior Apprehension- integrity of GH joint, instability
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Painful Arc- pain btwn 60-120 supraspinatus tendonitis, pain btwn 150-180 AC joint, non painful resisted ER rules out subacromial impingement
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O'Brien Test- ddx SLAP (deep pain) or AC (superficial); pain in pronation, decreased pain in supination
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Wright's Test- TOS
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Additional notes
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Elbow/Wrist/Hand
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Observation:
• • •
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Palpation (Spasm)
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Palpation (Trigger Points)
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Elbow/Wrist/Hand Passive ROM:
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Elbow/Wrist/Hand Active ROM:
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Manual Muscle Testing:
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Elbow/Wrist/Hand Orthopedic Tests
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Valgus Stress Test- medial side/ulnar
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Varus Stress Test- lateral side, radial
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Mill's Test- lateral epicondylistis (tennis elbow)
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Reverse Mill's Test- medial epicondylitis (golfer's elbow)
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Cozen's Test- lateral epicondyle, strength test, tennis elbow
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Reverse Cozen's- medial epicondyle, golfer's elbow, strength test
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Tinel's Test- ulnar n. compression
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Phalen's Test- CTS
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TFCC Lift Test- patient supinates arms and lifts table
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Finkelstein's Test
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Bracelet Test- wrist instability
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TFCC Compression Test
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Additional notes
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Knee/Ankle/Foot
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Observation:
• • •
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Palpation (Spasm)
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Palpation (Trigger Points)
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Knee
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Knee Passive ROM
• • •
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Knee Active ROM
• • •
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Knee Manual Muscle Testing
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Knee Orthopedic Tests
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Anterior Drawer Test- ACL
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Posterior Drawer Test- PCL
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Lachman's- ACL
• • •
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Modified Clarke's (Patellar Grind Test)- chondromalacia patella, patellofemoral pain syndrome, DJD
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McMurray's
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Hyperflexion Test-"locking" or "catching" sensation during hyperflexion or hyperflexion with rotation indicates positive; potential meniscal tear or other knee pathology
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Valgus Stress Test (MCL)
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Varus Stress Test (LCL)
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Femoral Nerve Tension Test; ddx tight RF, upper lx hernation (btwn 80-100 deg)
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Renne/Ober/Nobel (ITB length test)
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Additional notes
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Ankle/Foot Exam
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Ankle/Foot Passive ROM
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Ankle/Foot Active ROM
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Ankle/Foot Manual Muscle Testing
• • •
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Ankle/Foot Orthopedic Tests
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Anterior Drawer Test (anterior talofibular ligament, ankle hypermobility)
• • •
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Posterior Drawer Test (posterior talofibular ligament, ankle hypermobility)
• • •
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Achilles Squeeze/ Thompson Test
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Morton's Squeeze (metatarsal neuroma)
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Additional notes
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Assessment
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Diagnosis
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Comments on DX
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Prognosis
• • •
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Comments
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Plan:
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Treatment Frequency:
• • •
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Goals:
• • •
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Modified Activity:
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Re-examination:
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New Patient office visit 99203
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Re-evaluation 99212
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Chiropractic Adjustments 98940 1-2 regions
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Chiropractic Adjustments 98941 3-4 regions
• • •
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Chiropractic Adjustments 98941 5 regions
• • •
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Extraspinal Adjustments 98943
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Therapeutic Exercise 97110 59
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Manual Therapy Techniques 97140
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Therapeutic Activities 97530
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Cold Pack 97010
• • •
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Neuromuscular Re-Ed 97112 59
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Recommendations:
• • •
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Radiology Referral
• • •
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Provider Referral
• • •
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Comments
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Discussion
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Medicare Y/N
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Treatment tolerated well
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Sign Note
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Signature
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Transfer from previous EMR?
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