Musculoskeletal and Neurovascular Systems Chelsea Warren shadow health Objective Data

Uncategorized

Musculoskeletal and Neurovascular Systems Chelsea Warren shadow health Objective Data

Objective Data Collection: 22 of 24 (91.67%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed
 Assessed Growth
1 of 1 point
Bmi For Age (1/2 point)
  •  Underweight
  •  Normal Weight
  •  Overweight
  •  Obese
Stature For Age (1/2 point)
  •  Percentile <= 5
  •  Percentile > 5 and < 95
  •  Percentile >= 95
 Inspected Hips
1 of 1 point
Symmetry (1/2 point)
  •  Symmetric Bilaterally
  •  Asymmetric
Appearance (1/2 point)
  •  No visible abnormal findings
  •  Discoloration
  •  Irregular alignment
  •  Laceration, lesion, or wound
  •  Rash
  •  Redness
  •  Visible mass
  •  Visible pulsation
 Inspected Legs
1 of 1 point
Symmetry (1/3 point)
  •  Symmetric bilaterally
  •  Asymmetric
Right: Appearance (1/3 point)
  •  No visible abnormal findings
  •  Discoloration
  •  Edema
  •  Irregular alignment
  •  Laceration, lesion, or wound
  •  Rash
  •  Redness
Left: Appearance (1/3 point)
  •  No visible abnormal findings
  •  Discoloration
  •  Edema
  •  Irregular alignment
  •  Laceration, lesion, or wound
  •  Rash
  •  Redness
 Inspected Knees
1 of 1 point
Symmetry (1/3 point)
  •  Symmetric bilaterally
  •  Asymmetric
Right: Appearance (1/3 point)
  •  No visible abnormal findings
  •  Discoloration
  •  Edema
  •  Irregular alignment
  •  Joint deformity
  •  Laceration, lesion, or wound
  •  Rash
  •  Redness
  •  Visible mass
Left: Appearance (1/3 point)
  •  No visible abnormal findings
  •  Discoloration
  •  Edema
  •  Irregular alignment
  •  Joint deformity
  •  Laceration, lesion, or wound
  •  Rash
  •  Redness
  •  Visible mass
 Inspected Ankles
1 of 1 point
Symmetry (1/3 point)
  •  Symmetric bilaterally
  •  Asymmetric
Right: Appearance (1/3 point)
  •  No visible abnormal findings
  •  Discoloration
  •  Edema
  •  Irregular alignment
  •  Joint deformity
  •  Laceration, lesion, or wound
  •  Rash
  •  Redness
Left: Appearance (1/3 point)
  •  No visible abnormal findings
  •  Discoloration
  •  Edema
  •  Irregular alignment
  •  Joint deformity
  •  Laceration, lesion, or wound
  •  Rash
  •  Redness
 Inspected Feet
1 of 1 point
Symmetry (1/3 point)
  •  Symmetric bilaterally
  •  Asymmetric
Right: Appearance (1/3 point)
  •  No visible abnormal findings
  •  Discoloration
  •  Edema
  •  Irregular alignment
  •  Joint deformity
  •  Laceration, lesion, or wound
  •  Rash
  •  Redness
Left: Appearance (1/3 point)
  •  No visible abnormal findings
  •  Discoloration
  •  Edema
  •  Irregular alignment
  •  Joint deformity
  •  Laceration, lesion, or wound
  •  Rash
  •  Redness
 Palpated Popliteal Pulse
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated Dorsalis Pedis Pulse
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated Posterior Tibial Pulse
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Patella Stability
1 of 1 point
Right Patella (1/2 point)
  •  No abnormal findings
  •  Bony Prominence
  •  Reported tenderness
Left Patella (1/2 point)
  •  No abnormal findings
  •  Bony Prominence
  •  Reported tendernessMusculoskeletal and Neurovascular Systems Chelsea Warren shadow health Objective Data
 Knee Joint Stability
1 of 1 point
Right Knee Joint (1/2 point)
  •  No abnormal findings
  •  Bony Prominence
  •  Crepitus, popping or clicking
  •  Effusion
  •  Reported tenderness
  •  Sensation of warmth
Left Knee Joint (1/2 point)
  •  No abnormal findings
  •  Bony Prominence
  •  Crepitus, popping or clicking
  •  Effusion
  •  Reported tenderness
  •  Sensation of warmth
 Tibial Tuberosity
1 of 1 point
Right Tibial Tuberosity (1/2 point)
  •  No abnormal findings
  •  Bony Prominence
  •  Reported tenderness
Left Tibial Tuberosity (1/2 point)
  •  No abnormal findings
  •  Bony Prominence
  •  Reported tenderness
  • Musculoskeletal and Neurovascular Systems Chelsea Warren shadow health Objective Data
 Tested Hips Range of Motion
1 of 1 point
Flexion (1/4 point)
  •  Expected range of motion (approx. 90 degrees)
  •  Reduced hip flexion
Extension (1/4 point)
  •  Expected range of motion (approx. 30 degrees)
  •  Reduced hip extension
Abduction (1/4 point)
  •  Expected range of motion (approx. 45 degrees)
  •  Reduced hip abduction
Adduction (1/4 point)
  •  Expected range of motion (approx. 30 degrees)
  •  Reduced hip adduction
 Tested Knees Range of Motion
1 of 1 point
Right: Flexion (1/4 point)
  •  Expected range of motion (approx. 130 degrees)
  •  Reduced flexion
Left: Flexion (1/4 point)
  •  Expected range of motion (approx. 130 degrees)
  •  Reduced flexion
Right: Extension (1/4 point)
  •  Expected range of motion (approx. 0 to 15 degrees)
  •  Reduced extension
Left: Extension (1/4 point)
  •  Expected range of motion (approx. 0 to 15 degrees)
  •  Reduced extension
 Tested Ankles Range of Motion
1 of 1 point
Right: Eversion And Inversion (1/4 point) Musculoskeletal and Neurovascular Systems Chelsea Warren shadow health Objective Data
  •  Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees)
  •  Reduced inversion
  •  Reduced eversion
Left: Eversion And Inversion (1/4 point)
  •  Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees)
  •  Reduced inversion
  • Musculoskeletal and Neurovascular Systems Chelsea Warren shadow health Objective Data
  •  Reduced eversion
Right: Dorsiflexion And Plantar Flexion (1/4 point)
  •  Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)
  •  Reduced dorsiflexion
  •  Reduced plantar flexion
Left: Dorsiflexion And Plantar Flexion (1/4 point)
  •  Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)
  •  Reduced dorsiflexion
  •  Reduced plantar flexion
 Tested Hip Strength
0 of 1 point
Strength (No point)
  •  0 – No muscle contraction
  •  1 – Barely detectable contraction
  •  2 – Active movement with gravity eliminated
  •  3 – Active movement against gravity
  •  4 – Active movement against gravity and resistance
  •  5 – Active movement against full resistance without fatigue (normal)
 Tested Knee Strength
1 of 1 point
Right (1/2 point)
  •  0 – No muscle contraction
  •  1 – Barely detectable contraction
  •  2 – Active movement with gravity eliminated
  •  3 – Active movement against gravity
  •  4 – Active movement against gravity and resistance
  •  5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
  •  0 – No muscle contraction
  •  1 – Barely detectable contraction
  •  2 – Active movement with gravity eliminated
  •  3 – Active movement against gravity
  •  4 – Active movement against gravity and resistance
  •  5 – Active movement against full resistance without fatigue (normal)
 Tested Ankle Strength
0 of 1 point
Right (No point)
  •  0 – No muscle contraction
  •  1 – Barely detectable contraction
  •  2 – Active movement with gravity eliminated
  •  3 – Active movement against gravity
  •  4 – Active movement against gravity and resistance
  •  5 – Active movement against full resistance without fatigue (normal)
Left (No point)
  •  0 – No muscle contraction
  •  1 – Barely detectable contraction
  •  2 – Active movement with gravity eliminated
  •  3 – Active movement against gravity
  •  4 – Active movement against gravity and resistance
  •  5 – Active movement against full resistance without fatigue (normal)
  • Musculoskeletal and Neurovascular Systems Chelsea Warren shadow health Objective Data
 Tested Deep Tendon Reflexes in Patellar Tendon
1 of 1 point
Right (1/2 point)
  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus
Left (1/2 point)
  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus
  • Musculoskeletal and Neurovascular Systems Chelsea Warren shadow health Objective Data
 Tested Deep Tendon Reflexes in Achilles Tendon
1 of 1 point
Right (1/2 point)
  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus
Left (1/2 point)
  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus
  • Musculoskeletal and Neurovascular Systems Chelsea Warren shadow health Objective Data
 Tested Sensation in Legs
1 of 1 point
Right Touch (1/2 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Left Touch (1/2 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
 Tested Sensation in Feet
1 of 1 point
Right (1/2 point)
  •  Expected sensation
  •  Decreased sensation
Left (1/2 point)
  •  Expected sensation
  •  Decreased sensation
 Observed Gait
1 of 1 point
Step Length (1/5 point)
  •  Stepping foot passes stationary foot
  •  Stepping foot does not pass stationary foot
Step Height (1/5 point)
  •  Step height is appropriate and symmetric
  •  Step height is not appropriate or non symmetric
Step Symmetry (1/5 point)
  •  Right and left step length equal
  •  Right and left step length unequal
Step Continuity (1/5 point)
  •  Steps are continuous
  •  Discontinuity between steps
Path (1/5 point)
  •  No deviation of path
  •  Some path deviation or use of walking aid
  •  Significant path deviation
 Observed Squat
1 of 1 point
Symmetry (1/6 point)
  •  Symmetric
  •  Asymmetric
Balance (1/6 point)
  •  Maintained balance
  •  Did not maintain balance
Joint Clicking (1/6 point)
  •  Clicking is not audible
  •  Clicking is audible
Discomfort (1/6 point)
  •  No discomfort with activity
  •  Expresses discomfort with activity
Toleration (1/6 point)
  •  Tolerates activity to completion
  •  Does not tolerate activity
Range Of Motion (1/6 point)
  •  Full range
  •  Less than full range
  • Musculoskeletal and Neurovascular Systems Chelsea Warren shadow health Objective Data
Reference no: EM132069492

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