Shoulder Objective

Exam
General appearance: [checkbox name="variable_1" value="Elevated left shoulder|Elevated right shoulder|Bilateral shoulders rolled forward|No Erythema|Erythema left shoulder|Erythema right shoulder|No Swelling or joint effusion|Swelling/joint effusion left side|Swelling/joint effusion right side|No Ecchymosis present (no recent trauma suspected)|Ecchymosis present left side (recent trauma suspected)|Ecchymosis present right side (recent trauma suspected)|No scars suggesting old trauma left shoulder|No scars suggesting old trauma right shoulder|Scars suggesting old trauma left shoulder|Scars suggesting old trauma right shoulder|No observable deformity of left sternoclavicular joint|No observable deformity of right sternoclavicular joint|Observable deformity of left sternoclavicular joint|Observable deformity of right sternoclavicular joint|No observable deformity of left Sternoclavicular Joint|No observable deformity of right Sternoclavicular Joint|Observable deformity of left Sternoclavicular Joint|Observable deformity of right Sternoclavicular Joint|No observable deformity of left Clavicle|No observable deformity of right Clavicle|Observable deformity of left Clavicle|Observable deformity of right Clavicle|No observable deformity of left Acromioclavicular joint|No observable deformity of right Acromioclavicular joint|Observable deformity of left Acromioclavicular joint|Observable deformity of right Acromioclavicular joint|No observable deformity of left Glenohumeral joint |No observable deformity of right Glenohumeral joint |Observable deformity of left Glenohumeral joint |Observable deformity of right Glenohumeral joint"] 

Palpation: [checkbox name="variable_2" value="No tenderness to palpation left acromioclavicular joint|No tenderness to palpation right acromioclavicular joint|Tenderness to palpation left acromioclavicular joint|Tenderness to palpation right acromioclavicular joint|No tenderness to palpation left biceps tendon|No tenderness to palpation right biceps tendon|Tenderness to palpation left biceps tendon|Tenderness to palpation right biceps tendon|No tenderness to palpation left coracoid|No tenderness to palpation right coracoid|Tenderness to palpation left coracoid|Tenderness to palpation right coracoid|No tenderness to palpation left subacromial space|No tenderness to palpation right subacromial space|Tenderness to palpation left subacromial space|Tenderness to palpation right subacromial space"]

ROM
Forward Flexion of Shoulder (Normal 180 degrees)
Left: [text name="variable_1" default=""]. [checkbox name="variable_3" value="No pain with movement.|Pain with movement."]
Right: [text name="variable_2" default=""]. [checkbox name="variable_4" value="No pain with movement.|Pain with movement."]
Abduction of shoulder (Normal 180 degrees)
Left: [text name="variable_3" default=""]. [checkbox name="variable_5" value="No pain with movement.|Pain with movement."]
Right: [text name="variable_4" default=""]. [checkbox name="variable_6" value="No pain with movement.|Pain with movement."]

External rotation of shoulder (Normal at least 30 degrees)
Left: [text name="variable_5" default=""]. [checkbox name="variable_7" value="No pain with movement.|Pain with movement."]
Right: [text name="variable_6" default=""]. [checkbox name="variable_8" value="No pain with movement.|Pain with movement."]

Internal rotation of shoulder (Level T4-T8 considered normal)
Left: [text name="variable_7" default=""]. [checkbox name="variable_9" value="No pain with movement.|Pain with movement."]
Right: [text name="variable_8" default=""]. [checkbox name="variable_10" value="No pain with movement.|Pain with movement."]

Strength
Supraspinatus: [checkbox name="variable_11" value="Empty can sign negative left|Empty can sign negative right|Empty can sign positive left|Empty can sign positive right|Drop arm test negative left|Drop arm test negative right|Drop arm test positive left|Drop arm test positive right"]
Infraspinatus/Teres Minor: [checkbox name="variable_12" value="Resisted external rotation negative left|Resisted external rotation negative right|Resisted external rotation positive left|Resisted external rotation positive right"]
Subscapularis: [checkbox name="variable_13" value="Negative internal rotation lag sign left|Negative internal rotation lag sign right|Positive internal rotation lag sign left|Positive internal rotation lag sign right"]

Provocative Tests
Biceps: [checkbox name="variable_14" value="Yergason’s (resisted supination) negative left |Yergason’s (resisted supination) negative right|Yergason’s (resisted supination) positive left |Yergason’s (resisted supination) positive right |Speed’s (resisted flexion) negative left|Speed’s (resisted flexion) negative right|Speed’s (resisted flexion) positive left|Speed’s (resisted flexion) positive right"]
Impingement: [checkbox name="variable_15" value="Neer’s test negative left |Neer’s test negative right|Neer’s test positive left |Neer’s test positive right|Hawkins test negative left|Hawkins test negative right|Hawkins test positive left|Hawkins test positive right"]
Acromioclavicular: [checkbox name="variable_16" value="Scarf test negative left |Scarf test negative right|Scarf test positive left |Scarf test positive right"]
Exam
General appearance:

Palpation:

ROM
Forward Flexion of Shoulder (Normal 180 degrees)
Left: .
Right: .
Abduction of shoulder (Normal 180 degrees)
Left: .
Right: .

External rotation of shoulder (Normal at least 30 degrees)
Left: .
Right: .

Internal rotation of shoulder (Level T4-T8 considered normal)
Left: .
Right: .

Strength
Supraspinatus:
Infraspinatus/Teres Minor:
Subscapularis:

Provocative Tests
Biceps:
Impingement:
Acromioclavicular:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.67, 24 form elements, 52 boilerplate words, 8 text boxes, 16 checkboxes, 112 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: