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Physical Examination Findings
General• Conscious, coherent, wheelchair-borne, not in
cardiorespiratory distress
Vital Signs• BP: 110/70 (right and left arm, seated) • PR: 79 beats/min,regular • RR: 19 breaths/min, regular • Temp: not assessed
Measurements• Height: not assessed • Weight: not assessed • BMI: not assessed Skin• Dry skin, No skin discolorations, No skin
lesions
HEENT• Normocephalic, no facial asymmetry • Normal eye position and alignment,
hyperemic sclera, pink conjunctiva, no corneal and lens opacities, no exudates
• No ear deformities, lesions, nodules, discharge, odor, swelling, redness, foreign bodies, (+) dry cerumen
• Nose and throat not assessed
Chest and Lungs• Not assessed
Heart• Not assessed Abdomen• Not assessed
Extremities
Brachial Radial Femoral Popliteal Posterior Tibia
Dorsalis Pedis
Right ++ ++Regular
Not assessed
Not assessed
+ ++
Left ++ ++Regular
Not assessed
Not assessed
+ ++
(0) = absent (+) = decreased (++) = normal (+++) = hyperactive (Br) = bruit
Musculoskeletal Examination
Inspection
No skin changes, no swelling, no deformities
Range of Motion
Active Passive
Flexion Normal Normal
Extension Normal Normal
Side Flexion (right and left) Normal Normal
Rotation (right and left) Normal Normal
Palpation
No palpable nodules, no tenderness
Cervical Spine
Musculoskeletal Examination
Range of Motion
Active Passive
Forward flexion (right and left)
Normal Normal
Extension (right and left) Not assessed Not assessed
Abduction (right and left) Limited Limited
Internal and external rotation (right and left)
None None
Palpation
No palpable nodules, no tenderness
Shoulder Joint
Musculoskeletal Examination
Inspection
No skin changes, no swelling, no deformities
Range of Motion
Active Passive
Pronation Normal Normal
Supination None – Left sideLimited – Right side
None – Left sideLimited – Right side
Palpation
No palpable nodules, no tenderness
Forearm
Musculoskeletal Examination
Inspection
No skin changes, no swelling, no deformities
Range of Motion
Active Passive
Flexion Limited Limited
Extension Limited Limited
Ulnar deviation Limited Limited
Radial deviation Limited Limited
Palpation
No palpable nodules, no tenderness
Wrist
Musculoskeletal ExaminationInspection Active Movement Passive Movement
Left Hand
Boutonniere’s deformity on all fingers
Can make a fist (flexion at MCP) Finger abduction : thumb and
index Finger adduction: thumb and
index (-) extension at MCP on all
fingers (-) flexion/extension at PIP and
DIP
Thumb: flexion/extension at MCP
Index: flexion/extension at MCP Middle: flexion/extension
(limited) at MCP Ring: flexion/extension (limited)
at MCP Little: flexion at MCP (-) flexion/extension at PIP and
DIP
Right hand
Boutonniere’s deformity – thumb, middle, ringSwan neck deformity – index, little finger
Can make a fist (flexion at MCP) Finger abduction : thumb and
index Finger adduction: thumb and
index (-) extension at MCP on all
fingers (-) flexion/extension at PIP and
DIP
Thumb: flexion/extension at MCP
Index: flexion/extension at MCP Middle: flexion at MCP Ring: flexion at MCP Little: flexion at MCP (-) flexion/extension at PIP and
DIP
Musculoskeletal Examination
Inspection
Swelling of both knees
Range of Motion
Active Passive
Flexion Normal Normal
Extension None Limited
Palpation
No palpable nodules, no tenderness
Knees
Musculoskeletal Examination
Inspection
No deformities
Range of Motion
Active Passive
Plantar Flexion Normal Normal
Dorsiflexion Normal Normal
Inversion Normal Normal
Eversion Normal Normal
Toe extension Normal Normal
Toe flexion Normal Normal
Palpation
No palpable nodules, no tenderness
Ankle joint and foot
Neurologic Examination
• CN II: (+) Red-orange reflex• CN VIII: Rinne (+), Weber – no lateralization