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Shoulder Exam - SOAPnote.org
SHOULDER: Inspection of ***left/right*** shoulder reveals ***no deformity/normal fairly developed musculature without atrophy/some mild muscle atrophy/some sagging of the shoulder/obvious deformity***. Palpation of shoulder reveals pain with palpation of the ***AC joint/subacromial area/bicipital groove/pectoralis tendon***, no pain when palpating the ***AC joint/subacromial area/bicipital groove/pectoralis tendon***. Active ROM shows ***no discomfort/mild pain/moderate pain/severe pain/limitation of ROM/no limitation of ROM/no weakness/weakness/giving way/failure of full ROM/touching the opposite shoulder/Scarf sign/internal rotation to touch the small of the back/touching the back of the head/active abduction/active slow adduction/flexion against resistance/extension against resistance/resisted internal rotation/resisted external rotation/otherwise normal***. Passive ROM shows ***no discomfort/mild pain/moderate pain/severe pain/Neer's negative for pain/Neer's positive for pain/Hawkins negative for pain/Hawkins positive for pain/limitation of ROM/no limitation of ROM***. Exam of the biceps shows ***no pain with resisted flexion or pronation/pain with resisted flexion and pronation/mild pain on resisted elbow flexion/positive Speed's test/negative Speed's test***. Exam for laxity showed ***negative anterior apprehension test for subluxation or dislocation/positive anterior apprehension test for subluxation or dislocation confirmed with relocation test/Posterior apprehension test negative/Posterior apprehension test positive/Sulcus sign positive/Sulcus sign negative/Anterior slide test positive/Anterior slide test negative/Crank test positive/Crank test negative/O'Brien test positive in position 1 with 15 degrees adduction and thumb down with internal rotation and negative for pain or click in position 2 with palm up/O'Brien test negative/Hyperlaxity testing positive/Hyperlaxity testing negative/Thumb to forearm/hyperextension of elbow > 10 degrees/hyperextension of knee > 10 degrees/pinky finger extension > 90 degrees/able to place hands on floor while standing with knees straight***.
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posted by: Mark Morgan, M.D.
post/review dates: April 1, 2010; September 3, 2015
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