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.
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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