GUIDE TO CLIN ICAL M EDI CIN E I: PRACTI CALS

Dok T - The Unr eliabl e Sourc es

Spine and Ext remitie s
MATERIALS
Tape Measure
HAND AND WRIST
3 2 1 0 Technique Sample Report
Good morning, I’m Dr ______. May I know
Introduction/Permission your name? I’m going to examine your spine
and extremities, is that OK with you?
Technique: Inspection – lesions,
pigmentations, gross deformities.
Banggitin kung ano mismo yung normal
range of motion. Always do everything
Technique: Palpation – tenderness,
bilaterally
swelling, atrophy, nodules, crepitus
For the hands, wrists, and fingers, no visible
Fingernails – clubbing, color, abnormalities lesions, abnormal pigmentations or gross
deformities. Upon palpation, no tenderness,
swelling, atrophy, crepitus, or nodules. No
Range of Motion: Wrist – Flexion,
clubbing of nails, pink nail beds, no nail plate
extension, abduction, adduction
abnormalities. Range of motion is normal in
the wrist and fingers as to flexion, extension,
Range of Motion: Fingers – Flexion,
abduction, and adduction. Range of motion is
extension, abduction, adduction
normal in the thumbs as to flexion, extension,
Range of Motion: Thumb – Flexion, abduction, adduction, and opposition.
extension, abduction, adduction,
opposition
FOREARM
Technique: Inspection – lesions,
pigmentations, gross deformities
For the forearm, no visible lesions, abnormal
Technique: Palpation of landmarks: radius
pigmentations or gross deformities. Radius
and ulna
and ulna are palpable. No tenderness,
Technique: Palpation of muscles –
swelling, nodules or atrophy noted. Able to
tenderness, swelling, nodules, atrophy
execute pronation and supination
Range of Motion: pronation and supination
ELBOW JOINT
Technique: Inspection – lesions, Wag kalimutan magdala ng tape measure.
pigmentations, gross deformities Yung circumference daw ang lagi nalilimutan
Technique: Palpation of landmarks: gawin!
olecranon process, medial epicondyle,
lateral epicondyle For the elbow joint, no visible lesions,
abnormal pigmentations or gross deformities.
Technique: Palpation – tenderness, Olecranon process, medial epicondyle, lateral
swelling, nodules epicondyle are palpable. No tenderness,
swelling, nodules noted. Range of motion is
Range of Motion: flexion and extension normal as to flexion, extension, pronation,
(humeroulnar joint), pronation and and supination. Circumference above elbow
supination (humeroradial joint) is __ cm, both sides. Circumference below
elbow is ___ cm, both sides. No atrophy
Muscle circumference above and below
noted, arms are symmetrical.
joint (measure of atrophy/symmetry)
 UPPER ARM AND SHOULDER JOINT
3 2 1 0 Technique Sample Report
Technique: Inspection – lesions,
pigmentations, gross deformities For the upper arm and shoulder joint, no
visible lesions, abnormal pigmentations or
Technique: Palpation of landmarks:
gross deformities. Coracoid process, greater
coracoid process, greater tuberosity of
tuberosity of humerus, acromion, and the
humerus, acromion, scapula
scapula are palpable. No tenderness,
Technique: Palpation of muscles (biceps
swelling, nodules or atrophy noted. Able to
and triceps) – tenderness, swelling,
execute flexion, extension, abduction,
nodules, atrophy
adduction, internal rotation, external rotation
Range of Motion: flexion, extension,
bilaterally.
abduction, adduction, internal rotation,
external rotation
CERVICAL AND THORACOLUMBAR SPINE
Technique: Inspection FROM BEHIND –
lesions, pigmentations, gross deformities,
lateral curvature, symmetry of
scapula/shoulder
For the cervical and thoracolumbar spine, no
visible lesions, abnormal pigmentations or
Technique: Inspection FROM THE SIDE –
gross deformities. Spine is midline without
normal curvature
deviation, scapular height is symmetrical.
Vertebral curvatures are normal. Upon
Technique: Palpation and percussion of palpation and percussion, vertebral spines
vertebral spines/paravertebral muscles: and paravertebral muscles have no
tenderness, swelling, nodules, atrophy tenderness, swelling, nodules or atrophy.
Range of motion is normal in the cervical
spine as to flexion, extension, lateral flexion,
Range of Motion CERVICAL SPINE: flexion,
and rotation. Range of motion is normal in
extension, lateral flexion, rotation
the thoracolumbar spine as to flexion,
extension, lateral flexion, and rotation.
Range of Motion THORACOLUMBAR SPINE:
flexion, extension, lateral flexion, rotation

HIP JOINT

Technique: Inspection – lesions, Di na samin pinapalpate ang pubic tubercle.

pigmentations, gross deformities Sa inyo ba? =D Aralin ang mga special
tests!!!!
Technique: Palpation of landmarks: iliac
For the hip joint, no visible lesions, abnormal
crest, iliac tubercle, greater trochanter,
pigmentations or gross deformities. iliac
pubic tubercle
crest, iliac tubercle, greater trochanter, pubic
tubercleare palpable. No tenderness,
Range of Motion: flexion, extension,
swelling, nodules noted. Range of motion is
adduction, abduction, internal rotation,
bilaterally normal as to flexion, extension,
external rotation
adduction, abduction, internal rotation, and
external rotation. Negative results for
Special tests: Trendelenburg, Graenslen’s, Trendelenburg, Graenslen’s, Thomas and
Thomas, Patrick, etc. Patrick Test.
 KNEE JOINT
3 2 1 0 Technique Sample Report
Technique: Inspection – lesions,
pigmentations, gross deformities
For the knee joint, no visible lesions,
abnormal pigmentations or gross deformities.
Technique: Palpation of landmarks: patella
Patella is palpable. No tenderness, swelling,
nodules noted. No anterior or posterior knee
Technique: Palpation - tenderness, cysts detected. Range of motion is bilaterally
swelling, nodules, knee cysts, effusion, normal as to flexion, extension.
Circumference above knee is __ cm, both
sides. Circumference below knee is ___ cm,
Range of Motion: flexion, extension,
both sides. No atrophy noted, legs are
symmetrical
Muscle circumference above and below
joint (measure of atrophy/symmetry)
ANKLE JOINT AND FOOT

Technique: Inspection – lesions,

pigmentations, gross deformities.

Technique: Palpation of landmarks: lateral

For the ankle joint and foot, no visible
malleolus, medial malleolus
lesions, abnormal pigmentations or gross
deformities. Lateral malleolus and medial
malleolus are palpable. No tenderness,
Technique: Palpation – tenderness,
swelling, nodules, or edema noted. No
swelling, nodules, edema
clubbing of nails, pink nail beds, no nail plate
abnormalities. Range of motion is bilaterally
normal as to inversion, eversion, dorsiflexion,
Fingernails – clubbing, color, abnormalities and plantar flexion

Range of Motion: inversion, eversion,

dorsiflexion, plantar flexion