Tina Jones – Musculoskeletal Results Health Assessment – January 2023
Tina Jones – Musculoskeletal Results Health Assessment – January 2023
Transcript
All Lines (135)Interview Questions (28)Statements (2)Exam Actions (105)
| Hello! |
| Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. |
| What is the situation? |
| It’s 8 a.m. on Tina Jones’ second morning as a patient here at Shadow General Hospital. Ms. Jones has a physical therapy consultation later today. Your role in this simulation is that of healthcare provider who will perform a full musculoskeletal system exam on Ms. Jones so that her therapist can understand Ms. Jones’ musculoskeletal health and customize therapy accordingly. |
| What are my objectives in this assessment? |
| In your interview with Ms. Jones, you will ask about her musculoskeletal system and identify any risk factors or complications. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to the musculoskeletal system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her musculoskeletal system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ musculoskeletal system to gather objective data about the system’s health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. |
| What else will this exam involve? |
| You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation. |
| How will I be evaluated? |
| In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 50 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically. |
| How does this assignment prepare me for the real world? |
| In this assessment, you will become familiarized with the structure and content of musculoskeletal exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data. |
| In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What precautions should you take with a patient that is a fall risk? |
| Remove hazards and ensure the patient has sensible shoes, the room is well lit and provide the patient with assistive device. |
| Time to begin. |
| Hello, my name is Nukol. I will be your nurse today. |
| Hey. |
| Vitals measured |
| Do you have joint pain? |
| My joints don’t hurt. |
| Are you able to walk? |
| I can walk by myself now, but it still hurts a lot. |
| I am sorry for the pain |
| Thanks. |
| What is the pain on a rating scale? (Clarified to What is your pain rating?.) |
| I’d give it a 5 or 6 out of 10 right now. (Clarified to how I would rate my pain.) |
| What is the pain rate while walking? (Clarified to Can you rate the pain when walking on a scale from 1 to 10?.) |
| It still hurts a lot to walk on. I’d say at least 7, maybe 8. (Clarified to how I would rate my pain when walking.) |
| Are you able to stand? |
| Last time I tried to stand normally it really hurt my foot, but at least I was able to stand on it. I’m hoping it’ll be better soon. |
| Do you have muscle soreness? |
| It’s not my muscles that are hurting. |
| Do you have ankle pain? |
| My ankles are fine. |
| Does your work cause any joint pain? |
| Nothing at work bothers me physically at all. . . I just haven’t been able to go because I can’t really stand or move around lately. |
| Does the pain affect your daily living? |
| I couldn’t really do much at all the last couple days without help. I’m glad my mom and sister were there to help, and the nurses here, too. Now, though, I feel like I can start to do things for myself again. My foot still hurts, but not nearly as bad. |
| Are your joints stiff? |
| No, I’m not stiff anywhere now. |
| Do you have a history of back pain? |
| I don’t usually have any back pain. Sometimes it aches a little, but nothing bad. |
| Have you ever injured your muscles? (Clarified to Has your muscle ever been pulled?.) |
| I can’t remember my muscles hurting ever. . . at least not enough for it to worry me. (Clarified to if I have ever pulled a muscle.) |
| Do you have a history of joint injury? |
| No, not really. |
| Do you have a history of fractures? |
| I’ve never broken a bone or anything like that. |
| Do you have a history of sprains? |
| I can’t remember spraining anything before. . . maybe in grade school? I did something to one of my fingers playing tether ball, I think. But nothing since then. |
| Do you have any neck pain? |
| My neck doesn’t hurt at all. |
| How is the range of motion of your body parts? (Clarified to How is your range of motion?.) |
| It hurts to move my foot, but I can do it. And everything else seems fine. [AUDIO COMING SOON] (Clarified to how my range of motion is.) |
| Do you have any muscle problem? |
| I don’t have any problems with my muscles. |
| Have you ever fallen? |
| I didn’t fall onto the ground. . . it was like, my foot just slipped as I stepped onto the ladder, but I caught my balance before I could topple over or anything. |
| I am sorry for that |
| Thanks. |
| Do you have a family history of osteoporosis? |
| No one in the family has osteoporosis that I know of. |
| Do you have a family history of joint problems? |
| I don’t know of any joint problems in the family. |
| Do you have a family history of bone cancer? |
| Oh wow — no, not that I know of. |
| Tested spinal ROM – flexion: Expected |
| Tested spinal ROM – extension: Expected |
| Tested spinal ROM – lateral bending: Expected |
| Tested spinal ROM – rotation to the left: Expected |
| Tested spinal ROM – rotation to the right: Expected |
| Tested ROM of neck – extension: Expected |
| Tested ROM of neck – flexion: Expected |
| Tested ROM of neck – lateral bending: Expected |
| Inspected front of neck |
| Inspected right side of neck |
| Inspected back of neck |
| Inspected left side of neck |
| Inspected front of neck |
| Inspected left side of neck |
| Inspected back of neck |
| Inspected right side of neck |
| Inspected front of neck |
| Inspected shoulders from the front |
| Inspected right shoulder |
| Inspected upper back |
| Inspected left shoulder |
| Inspected shoulders from the front |
| Inspected left shoulder |
| Inspected upper back |
| Inspected right shoulder |
| Inspected shoulders from the front |
| Inspected left arm |
| Inspected right arm |
| Inspected right elbow |
| Inspected left elbow |
| Inspected right wrist |
| Inspected both wrists |
| Inspected left wrist |
| Inspected right hand |
| Inspected both hands |
| Inspected left hand |
| Inspected front of hips |
| Inspected right side of hips |
| Inspected back of hips |
| Inspected left side of hips |
| Inspected front of hips |
| Inspected left side of hips |
| Inspected back of hips |
| Inspected right side of hips |
| Inspected front of hips |
| Inspected front of thighs |
| Inspected right thigh |
| Inspected back of thighs |
| Inspected left thigh |
| Inspected front of thighs |
| Inspected left thigh |
| Inspected back of thighs |
| Inspected right thigh |
| Inspected front of thighs |
| Inspected front of knees |
| Inspected right knee |
| Inspected back of knees |
| Inspected left knee |
| Inspected front of knees |
| Inspected left knee |
| Inspected back of knees |
| Inspected right knee |
| Inspected front of knees |
| Inspected front of legs |
| Inspected right leg |
| Inspected back of legs |
| Inspected left leg |
| Inspected front of legs |
| Inspected left leg |
| Inspected back of legs |
| Inspected right leg |
| Inspected front of legs |
| Inspected left ankle |
| Inspected both ankles |
| Inspected right ankle |
| Inspected both ankles |
| Inspected left ankle |
| Inspected left foot |
| Inspected soles of feet: Right: Laceration and swelling, expected curvature. Left: No visible abnormal findings, expected curvature. |
| Inspected left foot |
| Inspected top of feet |
| Inspected left foot |
| Inspected top of feet |
| Inspected right foot |
| Inspected top of feet |
| Inspected right foot |
| Inspected soles of feet: Right: Laceration and swelling, expected curvature. Left: No visible abnormal findings, expected curvature. |
| Inspected right foot |
| Inspected soles of feet: Right: Laceration and swelling, expected curvature. Left: No visible abnormal findings, expected curvature. |
| Inspected left foot |
| Inspected top of feet |
| Tested ROM of shoulders – adduction: Expected |
| Tested ROM of shoulders – extension: Expected |
| Tested ROM of shoulders – flexion: Expected |
| Tested ROM of elbows – flexion and extension: Expected |
| Tested ROM of elbows – supination and pronation: Expected |
| Tested ROM of wrists – ulnar and radial deviation: Expected |
| Tested ROM of wrists – extension: Expected |
| Tested ROM of wrists – flexion: Expected |
| Tested ROM of hips – abduction: Expected |
| Tested ROM of hips – adduction: Expected |
| Tested ROM of hips – extension: Expected |
| Tested ROM of hips – flexion: Expected |
| Tested ROM of knees – extension: Expected |
Subjective Data Collection: 23 of 23 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Relevant Medical History
Finding:
Asked about joint problems
Finding:
Denies joint pain
(Found)
Pro Tip: Uncovering if Tina has any joint pain is important, as they could be a result of her recent foot injury and could contribute to impaired mobility.
Example Question:
Do you have joint pain?
Finding:
Denies joint swelling
(Available)
Pro Tip: Uncovering if Tina has any swollen joints is important, as they could be a result of her recent foot injury and could contribute to impaired mobility.
Example Question:
Do you have swollen joints?
Finding:
Asked about mobility
Finding:
Denies history of walking problems
(Available)
Pro Tip: Discovering if Tina has a history of walking problems is imperative because it could show that her mobility issues predate the foot wound.
Example Question:
Have you ever had problems walking?
Finding:
Reports recent foot wound hindered mobility
(Found)
Pro Tip: People with severe pain might find that they are limited in their movements. Asking Tina whether the pain makes it hard for her to walk would illustrate whether her pain is preventing her from some of the activities that comprise her daily life.
Example Question:
Has your wound affected your mobility?
Finding:
Reports ability to walk on foot has recently improved
(Found)
Pro Tip: Determining if Tina’s mobility has recently improved will provide key information as to the healing process and what further steps are needed.
Example Question:
Has your mobility changed lately?
Finding:
Asked pain rating when walking
Finding:
Reports pain as a 7 or 8/10 when walking
(Found)
Pro Tip: People with severe pain might find that they are limited in their movements. Having Tina rank her pain on a scale will help you judge the severity of the wound and help you determine treatment needs.
Example Question:
How would you rate your pain when walking?
Finding:
Asked about ability to stand
Finding:
Denies trouble standing before foot problems
(Available)
Pro Tip: Asking Tina if she has a history of standing problems will reveal the severity of her injury and whether her standing problem predated her foot injury.
Example Question:
Do you have a history of standing problems?
Finding:
Reports recent foot wound hindered standing
(Found)
Pro Tip: Asking Tina if she can stand on her foot will reveal the severity of her injury and whether or not she is able to put weight on her foot.
Example Question:
Has your wound affected your ability to stand?
Finding:
Reports improved ability to stand on injured foot
(Found)
Pro Tip: Asking Tina if she can stand on her foot will reveal the severity of her injury and whether or not she is able to put weight on her foot.
Example Question:
Are you able to stand on your foot?
Finding:
Asked pain rating when standing
Finding:
Reports pain as a 7 or 8/10 when bearing weight on foot
(Available)
Pro Tip: Asking Tina about the pain if she’s standing will reveal the severity of her injury and whether or not standing exacerbates her pain.
Example Question:
How would you rate your pain on a scale of 1 to 10 when you are standing?
Finding:
Asked about muscle soreness
Finding:
Denies history of muscle soreness
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she has ever had muscle soreness specifies the way her symptoms and pain manifest.
Example Question:
Have you ever had muscle soreness?
Finding:
Denies current muscle soreness
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she is having muscle soreness specifies the way her symptoms and pain manifest.
Example Question:
Are you having muscle soreness?
Finding:
Asked about joints in proximity of injury
Finding:
Denies current ankle problems
(Found)
Pro Tip: Ankle problems can greatly affect a patient’s mobility. Asking Tina if she has problems with her ankles can reveal a major health concern.
Example Question:
Are your ankles giving you trouble?
Finding:
Asked about occupational impact on injury
Finding:
Denies work being dangerous
(Found)
Pro Tip: Determining if Tina’s workplace is safe will allow you to establish any occupational dangers that could exacerbate her current health issues or pose further risks.
Example Question:
Is your work dangerous?
Finding:
Denies work involving repetitive motion
(Available)
Pro Tip: Establishing if Tina’s job requires repetitive motion, such as picking up boxes, can help you determine if those motions have had an impact on her health or pose potential risks.
Example Question:
Does your work involve repetitive motion?
Finding:
Reports foot wound prevented her from working
(Found)
Pro Tip: People with severe pain might find that they are unable to perform all of their daily activities. Asking Tina whether she has been able to work in spite of the pain would illustrate whether her pain is preventing her from activities that constitute her daily life.
Example Question:
Did your wound prevent you from working?
Finding:
Asked about activities of daily living
Finding:
Denies difficulty transferring from sitting to standing
(Found)
Pro Tip: As a result of Tina’s foot wound, there is the risk that certain activities of daily living have been compromised. It is important to identify any difficulties with transferring so her quality of life does not suffer.
Example Question:
Are you able to go from sitting to standing?
Finding:
Denies difficulty bathing
(Available)
Pro Tip: As a result of Tina’s foot wound, there is the risk that certain activities of daily living have been compromised. It is important to identify any difficulties with bathing so her quality of life does not suffer.
Example Question:
Can you bathe yourself?
Review of Systems
Finding:
Asked about joint stiffness
Finding:
Denies joint stiffness
(Available)
Pro Tip: Because Tina’s foot wound has recently impaired mobility, which often leads to joint stiffness, it is important to ask Tina about her joints to ascertain the impact of her wound and what treatment she may require.
Example Question:
Do you feel stiff anywhere?
Finding:
Asked about back pain
Finding:
Denies history of back pain
(Found)
Pro Tip: Back pain can be a serious complaint that compromises a patient’s quality of life. It is important to determine Tina has suffered from back pain so you can most effectively treat the issue.
Example Question:
Have you had back pain before?
Finding:
Denies current back pain
(Available)
Pro Tip: Back pain can be a serious complaint that compromises a patient’s quality of life. It is important to determine if Tina is currently suffering from back pain so you can most effectively treat the issue.
Example Question:
Are you having back pain?
Finding:
Asked about muscle injury
Finding:
Denies history of muscle injury
(Found)
Pro Tip: It is important to establish if Tina has a history of muscle injuries because it may contribute to her recent mobility issues.
Example Question:
Have you ever had a muscle injury?
Finding:
Denies current muscle injury
(Found)
Pro Tip: It is important to establish if Tina has a muscle injury because it might contribute to her recent mobility issues.
Example Question:
Do you have a muscle injury?
Finding:
Asked about joint injury
Finding:
Denies past joint injury
(Found)
Pro Tip: It is important to establish if Tina has a history of joint injuries because it may contribute to her recent mobility issues.
Example Question:
Have you experienced a joint injury in the past?
Finding:
Denies current joint injury
(Found)
Pro Tip: It is important to establish if Tina has a joint injury because it might contribute to her recent mobility issues.
Example Question:
Do you have a joint injury?
Finding:
Asked history of fracture
Finding:
Denies history of fractures
(Found)
Pro Tip: Soliciting your patient’s medical history can help you to understand the nature of a patient’s chief complaint. Asking Tina whether she’s ever broken a bone might reveal relevant concerns she’d previously experienced.
Example Question:
Have you ever broken a bone?
Finding:
Asked history of sprains
Finding:
Denies history of sprains
(Found)
Pro Tip: Soliciting your patient’s medical history can help you to understand the nature of a patient’s chief complaint. Asking Tina whether she has a history of getting sprains might reveal relevant concerns she’d previously experienced.
Example Question:
Do you have a history of getting sprains?
Finding:
Asked about bone problems
Finding:
Denies history of bone problems
(Found)
Pro Tip: Soliciting your patient’s medical history can help you to understand the nature of a patient’s chief complaint. Asking Tina whether she ever had bone problems might reveal relevant concerns she’d previously experienced.
Example Question:
Have you ever had bone problems?
Finding:
Denies current bone problems
(Available)
Pro Tip: Soliciting your patient’s medical history can help you to understand the nature of a patient’s chief complaint. Asking Tina whether she has bone problems might reveal relevant concerns she’d previously experienced.
Example Question:
Do you have bone problems?
Finding:
Asked about neck
Finding:
Denies history of neck problems
(Available)
Pro Tip: A history of neck problems may imply an illness or a problematic behavior in the patient. Asking Tina whether she has had neck problems in the past could prompt you to follow up on potential causes.
Example Question:
Have you had neck problems?
Finding:
Denies current neck problems
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she may be experiencing with her injury, like neck pain, details the way her individual symptoms and pain manifest.
Example Question:
Do you have neck problems?
Finding:
Asked about range of motion of body parts
Finding:
Reports normal range of motion
(Found)
Pro Tip: People with severe pain might find that they are limited in their movements. Asking Tina whether she is limited in her movements would illustrate whether her pain is preventing her from some of the activities that comprise her daily life.
Example Question:
Do you have full range of motion?
Finding:
Asked about muscle problems
Finding:
Denies muscle weakness
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like muscle weakness, details the way her individual symptoms and pain manifest.
Example Question:
Are you experiencing any muscle weakness?
Finding:
Denies muscle cramping
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like muscle cramping, details the way her individual symptoms and pain manifest.
Example Question:
Are you experiencing any muscle cramping?
Risk Factors
Finding:
Asked fall history
Finding:
Reports fall
(Found)
Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density.
Example Question:
Have you fallen before?
Finding:
Reports fall was one week ago
(Available)
Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density.
Example Question:
When was the last time you fell?
Finding:
Reports belief that she is not particularly prone to falls
(Available)
Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina if she is prone to falling could provide you with information about her bone density.
Example Question:
Are you prone to falling?
Finding:
Denies other recent falls
(Available)
Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density.
Example Question:
Did you have any other recent falls?
Finding:
Reports no dizziness or weakness before recent fall
(Available)
Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density.
Example Question:
Did you feel weak before you fell?
Relevant Family History
Finding:
Asked family history of osteoporosis
Finding:
Denies family history of osteoporosis
(Found)
Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has osteoporosis can indicate a potential predisposition.
Example Question:
Does anyone in your family have osteoporosis?
Finding:
Asked family history of joint problems
Finding:
Denies family history of joint problems
(Found)
Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has had joint problems can indicate a potential predisposition.
Example Question:
Has anyone in your family had joint problems?
Finding:
Denies family history of arthritis
(Available)
Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has arthritis can indicate a potential predisposition.
Example Question:
Does arthritis run in your family?
Finding:
Asked family history of bone cancer
Finding:
Denies family history of bone cancer
Objective Data Collection: 25.8 of 28 (92.14%)
Correct
Partially correct
Incorrect
Missed
Inspected neck
0.5 of 1 point
Symmetry (1/2 point)
Symmetric
Asymmetric
Appearance (No point)
No visible abnormal findings
Swelling
Visible pulsation
Visible mass
Irregular alignment
Discoloration
Inspected shoulders
1 of 1 point
Symmetry (1/3 point)
Symmetric bilaterally
Asymmetric
Right: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Left: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Inspected arms
1 of 1 point
Symmetry (1/3 point)
Symmetric bilaterally
Asymmetric
Right: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Atrophy
Hypertrophy
Left: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Atrophy
Hypertrophy
Inspected elbows
1 of 1 point
Symmetry (1/3 point)
Symmetric bilaterally
Asymmetric
Right: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Joint deformity
Left: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Joint deformity
Inspected wrists
1 of 1 point
Symmetry (1/3 point)
Symmetric bilaterally
Asymmetric
Right: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Atrophy
Hypertrophy
Joint deformity
Left: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Atrophy
Hypertrophy
Joint deformity
Inspected hands and fingers
1 of 1 point
Symmetry (1/3 point)
Symmetric bilaterally
Asymmetric
Right: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Joint deformity
Left: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Joint deformity
Inspected hips
1 of 1 point
Appearance (1/1 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Pelvic tilt
Inspected thighs
1 of 1 point
Symmetry (1/3 point)
Symmetric bilaterally
Asymmetric
Right: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Atrophy
Hypertrophy
Left: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Atrophy
Hypertrophy
Inspected knees
1 of 1 point
Symmetry (1/3 point)
Symmetric bilaterally
Asymmetric
Right: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Genu recurvatum
Discoloration
Joint deformity
Left: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Genu recurvatum
Discoloration
Joint deformity
Inspected lower legs
1 of 1 point
Symmetry (1/3 point)
Symmetric bilaterally
Asymmetric
Right: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Discoloration
Atrophy
Hypertrophy
Genu valgum
Genu varum
Left: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Discoloration
Atrophy
Hypertrophy
Genu valgum
Genu varum
Inspected ankles
1 of 1 point
Symmetry (1/3 point)
Symmetric bilaterally
Asymmetric
Right: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Joint deformity
Left: Appearance (1/3 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Joint deformity
Inspected feet
0.8 of 1 point
Symmetry (1/5 point)
Symmetric bilaterally
Asymmetric
Right: Appearance (No point)
No visible abnormal findings
Swelling
Laceration, lesion, or wound
Visible mass
Irregular alignment
Discoloration
Joint deformity
Hallux valgus
Hammertoe(s)
Mallet toe(s)
Claw toe(s)
Right: Arch Shape (1/5 point)
Expected curvature
Pes planus
Pes cavus
Left: Appearance (1/5 point)
No visible abnormal findings
Swelling
Laceration, lesion, or wound
Visible mass
Irregular alignment
Discoloration
Joint deformity
Hallux valgus
Hammertoe(s)
Mallet toe(s)
Claw toe(s)
Left: Arch Shape (1/5 point)
Expected curvature
Pes planus
Pes cavus
Tested neck range of motion
1 of 1 point
Extension (1/4 point)
Expected range of motion (approx. 45 degrees)
Reduced range of motion
Flexion (1/4 point)
Expected range of motion (approx. 45 degrees)
Reduced range of motion
Lateral Bending (1/4 point)
Expected range of motion (approx. 40 degrees) on both sides
Reduced range of motion on right
Reduced range of motion on left
Rotation (1/4 point)
Expected range of motion (approx. 70 degrees) on both sides
Reduced range of motion on right
Reduced range of motion on left
Tested shoulder range of motion
1 of 1 point
Adduction (1/3 point)
Expected range of motion (approx. 50 degrees)
Reduced range of motion
Extension (1/3 point)
Expected range of motion (approx. 50 degrees)
Reduced range of motion
Forward Flexion (1/3 point)
Expected range of motion (approx. 180 degrees)
Reduced range of motion
Tested elbow range of motion
1 of 1 point
Right: Flexion And Extension (1/4 point)
Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)
Reduced flexion
Reduced extension
Left: Flexion And Extension (1/4 point)
Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)
Reduced flexion
Reduced extension
Right: Supination And Pronation (1/4 point)
Expected range of motion (approx. pronation of 90 degrees and supination of 90 degrees)
Reduced pronation
Reduced supination
Left: Supination And Pronation (1/4 point)
Expected range of motion (approx. pronation of 90 degrees and supination of 90 degrees)
Reduced pronation
Reduced supination
Tested wrist range of motion
1 of 1 point
Right: Ulnar And Radial Deviation (1/6 point)
Expected range of motion (approx. ulnar radiation 55 degrees and radial deviation 90 degrees)
Reduced ulnar deviation
Reduced radial deviation
Left: Ulnar And Radial Deviation (1/6 point)
Expected range of motion (approx. ulnar radiation 55 degrees and radial deviation 90 degrees)
Reduced ulnar deviation
Reduced radial deviation
Right: Extension (1/6 point)
Expected range of motion (approx. 70 degrees)
Reduced extension
Left: Extension (1/6 point)
Expected range of motion (approx. 70 degrees)
Reduced extension
Right: Flexion (1/6 point)
Expected range of motion (approx. 90 degrees)
Reduced flexion
Left: Flexion (1/6 point)
Expected range of motion (approx. 90 degrees)
Reduced flexion
Tested spine range of motion
0.25 of 1 point
Extension (No point)
Expected range of motion (approx. 30 degrees)
Reduced extension
Flexion (1/4 point)
Expected range of motion (approx. 75 – 90 degrees)
Reduced flexion
Lateral Bending (No point)
Expected range of motion bilaterally (approx. 35 degrees)
Reduced lateral bending to the right
Reduced lateral bending to the left
Rotation (No point)
Expected range of motion bilaterally (approx. 30 degrees)
Reduced rotation to the right
Reduced rotation to the left
Tested hip range of motion
1 of 1 point
Abduction (1/4 point)
Expected range of motion (approx. 45 degrees)
Reduced hip abduction
Adduction (1/4 point)
Expected range of motion (approx. 30 degrees)
Reduced hip adduction
Extension (1/4 point)
Expected range of motion (approx. 30 degrees)
Reduced hip extension
Flexion (1/4 point)
Expected range of motion (approx. 90 degrees)
Reduced hip flexion
Tested knee range of motion
1 of 1 point
Right: Extension (1/4 point)
Expected range of motion (approx. 0 to 15 degrees)
Reduced extension
Left: Extension (1/4 point)
Expected range of motion (approx. 0 to 15 degrees)
Reduced extension
Right: Flexion (1/4 point)
Expected range of motion (approx. 130 degrees)
Reduced flexion
Left: Flexion (1/4 point)
Expected range of motion (approx. 130 degrees)
Reduced flexion
Tested ankle range of motion
0.75 of 1 point
Right: Eversion And Inversion (1/4 point)
Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees)
Reduced inversion
Reduced eversion
Left: Eversion And Inversion (1/4 point)
Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees)
Reduced inversion
Reduced eversion
Right: Dorsiflexion And Plantar Flexion (No point)
Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)
Reduced dorsiflexion
Reduced plantar flexion
Left: Dorsiflexion And Plantar Flexion (1/4 point)
Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)
Reduced dorsiflexion
Reduced plantar flexion
Tested neck strength
1 of 1 point
Strength (1/1 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Tested shoulder strength
1 of 1 point
Strength (1/1 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Tested elbow strength
1 of 1 point
Right (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Tested wrist strength
1 of 1 point
Right (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Tested hand strength
1 of 1 point
Right (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Tested hip strength
1 of 1 point
Strength (1/1 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Tested knee strength
1 of 1 point
Right (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Tested ankle strength
0.5 of 1 point
Right (No point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
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