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