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MUSCULOSKELETAL EXAM SOAP NOTE 1

Musculoskeletal Examination

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Hands – Inspection: No redness, swelling, atrophy, or nodules. When compared side by side, both hands were symmetrical, with no deformities noted.
Palpation: No swelling, redness, pain, or tender spots over the joint spaces upon palpation on DIP, PIP, and MCP.
ROM: Full ROM was noted on both hands, able to make a fist fist. Showed finger flexion and extension of the fingers. Both abduction and adduction of the fingers were also performed.

Wrist – Inspection: No swelling, deformity, redness, atrophy, nodules, and joints were symmetric.
Palpation: No tenderness or pain noted bilaterally upon palpation of the carpal bones and the metacarpals.
ROM: Full ROM and no pain was noted bilaterally in wrist flexion, extension, radial deviation, and ulnar deviation.
Specialty Test: Tinel’s and Phalen’s test were both negative, no paresthesia or pain noted.

Elbow – Inspection: No redness, swelling, nodules, and joints were symmetric.
Palpation: No swelling, pain, or tenderness upon palpation was noted on both lateral and medial epicondyles, olecranon process, and extensor surface of the ulna. Golfer’s/baseball’s elbow pain or tenderness is on the medial epicondyle, and tennis elbow pain or tenderness will be on lateral epicondyle.
ROM: Full ROM noted in flexion, extension, supination, and pronation bilaterally.

Shoulder – Inspection: No redness, swelling, deformations, atrophy, nodules, and both shoulder were symmetric.
Palpation: No fluid or tenderness was noted in the acromioclavicular joint, bicipital grooves, tubercle of the humerus, coracoid process, and subdeltoid bursa bilaterally.
ROM: Both shoulder has full ROM during flexion, extension, abduction, adduction, internal rotation, and external rotation bilaterally.
Specialty Test: Hawkin’s test was performed bilaterally, and no pain or weakness was demonstrated. Positive sign shows pain with internal rotation testing for supraspinatus tendonitis (Bickley et al., 2017)

Head and Neck – Inspection: Head and neck is midline. No deformities or abnormal posture noted.
Palpation: No pain or tenderness while assessing for TMJ, sternoclavicular joint, cervical spine, paracervical muscles, the trapezius muscles, and the rhomboid muscles upon palpation.
ROM: Full ROM of the TMJ, patient was able to place three fingers while jaw was open, and side to side lateral movement was also done with no pain. Full ROM of the neck was present during flexion, extension, rotation and lateral.
Specialty Test: Cervical compression test or Spurling’s test produced no pain or radiation of pain or paresthesia down the right or the left arm.

Feet and Toes – Inspection: No swelling, calluses, corns, deformity, plantar warts, discoloration, nodules, bunions and flat feet.
Palpation: No pain when palpated for Morton’s neuroma and plantar fasciitis. No pain or tenderness was felt on DIP, PIP, and metatarsals, and no nodules were palpated.

ROM: Full ROM with flexion, extension of toes, inversion and eversion of feet.

Ankles – Inspection: No redness, swelling, atrophy, nodules, or asymmetry noted in ankles.
Palpation: No pain, tenderness or nodules was noted over the medial and lateral malleolus and achilles.
ROM: Full ROM was noted in passive and active plantar flexion, dorsiflexion, inversion, and rotating ankles in circles.

Knees – Inspection: No swelling, nodules, deformity noted on knees, valgus and varus noted. Knees are aligned.
Palpation: No pain or tenderness noted upon palpation of suprapatellar pouch, the patella’s sides, and no Bakers cysts noted bilaterally in the popliteal fossa.
ROM: Both knee were able to flex and extend through the full active and passive ROM.
Specialty Test: Valgus stress test showed no laxity in the medial collateral ligament bilaterally. Varus stress test showed no ligament laxity in the lateral collateral ligament bilaterally. Lachman’s test showed no anterior or posterior laxity, and the Drawer test also showed no anterior or posterior laxity of the knee bilaterally. McMurry’s test showed no pain, laxity, or crepitus bilaterally.

Hips – Inspection: There was no swelling, redness, nodules, asymmetries noted in the hips.
Palpation: Palpation was performed to the anterior superior iliac spine, the greater trochanter, the posterior superior iliac spine, and the sacroiliac joints and no pain or tenderness was noted.
ROM: Full passive and active ROM was observed in the hip joint. The ranges of motion checked were flexion, extension, abduction, adduction, internal and external rotation.
Specialty Test: Thomas test was performed, and no occult hip flexion was noted. Patrick’s test was also performed, and there was no tenderness or pain in the hip/sacroiliac joint.

Spine – Inspection: No abnormal lordosis was noted in the cervical or lumbar spines, and no dorsal kyphosis was noted in the thoracic spine. Shoulders height, iliac crest and skin creases below buttocks were symmetrical. No scoliosis was noted upon having patient bend over to touch toes.
Palpation: No pain or tenderness upon palpation and percussion of spinous process and intervertebral spaces.
ROM: Full ROM upon flexion, extension, lateral, and rotation noted.

Reference

Bickley, l., Szilagyi, P., & Hoffman, R. (2017). Bates’ guide to physical examination and history taking 12th edition. Philadelphia: Lippincott Williams & Wilkins.

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