MUSCULOSKELTAL SAMPLE WRITE-UP
Below is a sample write-up of a patient without any significant physical exam findings.
Please pretend as though you saw one of disease cases from the handout given in class &
replace the physical exam findings below with those listed in the case. If no information
was given in the case, assume a normal finding (i.e. such as a finding from your lab
partner). (4 pts)
Provider Name: Dr. John Conner, M2, 382-FLEX
Date: Physical exam on Dec 5, 2010, 10:15 am
Patient ID: Name, age, date-of-birth, profession
CC: chief complaint and duration
Vital signs
Temp: 98 °F
Pulse: 60, regular rate and rhythm
Resp: 12
BP: 125/75 (sitting, right arm)
Pain: 0/10
2nd BP: 148/84 (seated, right arm)
Height: 5’ 3” (by pt. report) Pulse ox: (if provided)
Weight: 132# (by pt. report)
BMI: please calculate (kg/m2)
Cervical & Lumbar Spine
Inspection: Neck and spine have no noted deformities or signs of inflammation.
Curvature of cervical, thoracic, and lumbar spine are within normal limits. Bony features
of shoulders and hips are of equal height bilaterally. Posture is upright, and gait is
smooth and normal.
Palpation: Spinous processes of C7-L5 palpable, midline, and non-tender; No stepoffs. Back muscles are tight and tender between shoulder blades (rhomboids).
Range of motion (ROM): Flexion, extension, and side-to-side rotation of cervical
spine causes no discomfort. Flexion, extension, and rotation of the remaining spinal
column is within normal limits. Patient can flex forward and reach toes with minimal
pain. Lateral bending causes mild discomfort (at rhomboids) when bending to the right
and left side. Spurling’s maneuver was negative.
Strength & reflexes [will include in Neuro write-up].
Wrist, Hand, & Fingers
Right/Left hand dominant. No bony deformities, inflammation, or tenderness of bony
prominences. No anatomical snuff box tenderness; Full ROM in DIP, PIP, MCP, &
carpal joints & with supination and pronation. Phalen’s & Tinel’s tests were negative.
Elbow
No bony deformities, inflammation, or tenderness in olecranon, medial, lateral
epicondyle elbow. Full ROM upon flexion and extension. Cubital tunnel (Tinel’s),
milking maneuver were negative.
Shoulder
synched 2010 with M-S PE 1-9-08 and Dr. Paluska’s lecture
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No bony deformities, inflammation, or tenderness in rotator cuff, biceps tendon, or
acromioclavicular joint. Full ROM and strength in shoulder upon adduction, abduction,
internal and external rotation. Scapular winging, impingement sign, scratch test (internal
rotation), joint laxity, drop arm test were negative.
Hip
No bony deformities, inflammation, or tenderness in hip joint. Normal ROM upon
flexion & extension, internal & external rotation, abduction, & adduction. Full strength in
hip flexors/extensors, adductors/abductors. Crossed straight leg-raising sign negative
(sitting and supine).
Knee
No bony deformities, inflammation, or tenderness in bony prominences or soft tissue. No
baker’s cyst. Full ROM (extension/flexion). Limited internal and external rotation.
Medial, lateral meniscus; anterior, posterior cruciate ligaments ,medial & lateral
collateral ligaments intact as assessed with negative Anterior/Posterior Drawer signs,
Lachman’s, and McMurray’s Tests. No effusion, bulge/balloon sign.
Strength & reflexes [will include in Neuro write-up].
Foot, Ankle, & Toes
No bony deformities, inflammation, or tenderness in bony prominences or soft tissue of
foot or ankle. No pes planus. Full ROM dorsi/plantar flexion, inversion & eversion.
Tinel’s test negative.
Please include your suspected diagnosis for the cases given in the class handout, as well
as a brief (1 – 3 sentences) justification for your diagnosis.(1 pt)
synched 2010 with M-S PE 1-9-08 and Dr. Paluska’s lecture
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