General MSK exam
GEN: Alert and oriented in no acute distress. HEENT: Normocephalic, atraumatic. CHEST: Symmetric rise and effort NEURO: A&Ox3, otherwise as per below Musculoskeletal: Right Upper Extremity: No lacerations or abrasions. No obvious deformity. No edema or ecchymosis. Non-TTP clavicle, shoulder, arm, elbow, forearm, wrist, or hand. Compartments soft. Grossly normal AROM shoulder, elbow, wrist, hand. Strength: D 5/5 B 5/5 T 5/5 WE 5/5 WF 5/5 IO 5/5 SILT in Ax/M/R/U Motor intact to Ax/M/AIN/PIN/U Palpable Brachial/Radial pulses, brisk cap refill < 2 sec Left Upper Extremity: No lacerations or abrasions. No obvious deformity. No edema or ecchymosis. Non-TTP clavicle, shoulder, arm, elbow, forearm, wrist, or hand. Compartments soft. Grossly normal AROM shoulder, elbow, wrist, hand. Strength: D 5/5 B 5/5 T 5/5 WE 5/5 WF 5/5 IO 5/5 SILT in Ax/M/R/U Motor intact to Ax/M/AIN/PIN/U Palpable Brachial/Radial pulses, brisk cap refill < 2 sec Right Lower Extremity: Skin intact, no abrasions, ecchymosis, or lacerations Non-TTP hip, knee, leg, ankle, foot. Compartments soft. Grossly normal AROM in hip, knee, ankle. Strength: IP 5/5 Q 5/5 A 5/5 EHL 5/5 GSC 5/5 SILT in Sa/Su/SPN/DPN/Tibial Palpable DP/PT pulses, brisk cap refill < 2 sec Left Lower Extremity: skin intact; no abrasions, ecchymosis, or laceration Non-TTP hip, thigh, knee, leg, ankle, foot. Compartments soft. Grossly normal AROM in hip, knee, ankle. Strength: IP 5/5 Q 5/5 A 5/5 EHL 5/5 GSC 5/5 SILT in Sa/Su/SPN/DPN/Tibial Palpable DP/PT pulses, brisk cap refill < 2 sec Pelvis: Inspection: no ecchymosis, skin intact Stable to stress Non-TTP Spine: Inspection: no ecchymosis Palpation: C-spine non-TTP; no T/L-spine TTP, No step-off SILT in C5-T1, bilaterally SILT in L2-S1, bilaterally Motor: C5 C6 C7 C8 T1 Left 5/5 5/5 5/5 5/5 5/5 Right 5/5 5/5 5/5 5/5 5/5 L2 L3 L4 L5 S1 Left 5/5 5/5 5/5 5/5 5/5 Right 5/5 5/5 5/5 5/5 5/5 Perianal sensation intact. Rectal tone normal. Negative Babinski, Negative Hoffman's, No Clonus.
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