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Physical Assessment Guide: Part Iii - Musculoskeletal & Neurological Assessment Notes

The document provides a guide for conducting a physical assessment with a focus on the musculoskeletal and neurological systems. It includes sections to assess muscles, bones, joints, muscle strength, range of motion, and neurological functions like mental status, speech, memory, and level of consciousness. The assessor is prompted to inspect, palpate, and test various areas and movements, documenting any abnormalities, weaknesses, or limitations found.

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151 views

Physical Assessment Guide: Part Iii - Musculoskeletal & Neurological Assessment Notes

The document provides a guide for conducting a physical assessment with a focus on the musculoskeletal and neurological systems. It includes sections to assess muscles, bones, joints, muscle strength, range of motion, and neurological functions like mental status, speech, memory, and level of consciousness. The assessor is prompted to inspect, palpate, and test various areas and movements, documenting any abnormalities, weaknesses, or limitations found.

Uploaded by

allkhusairy6tuansi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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SAN PEDRO COLLEGE

PHYSICAL ASSESSMENT GUIDE


Part III – MUSCULOSKELETAL & NEUROLOGICAL ASSESSMENT

MUSCLES: Assess muscles supporting interphalangeal, NOTES


metacarpophalageal, wrist, elbow, shoulder, metatarsophalangeal, ankles,
knees, and hip joints. Specify which muscles correspond to findings,
Size equal disproportionate atrophy
hypertrophy contractures tremors
flaccidity spasticity
Specify:______________________________________________________
Test for MUSCLE STRENGTH (Compare L/R)
___sternocleidomastoid ___trapezius ___biceps
___triceps _____finger/wrist ____hip muscles (raising)
___hip muscles (abduction/adduction) ___hamstring
____quadriceps ___ankles/feet
Weakness at_________________________________________________
Numbness/Tingling at__________________________________________

Grade Description
0 No muscular contraction detected
1 A barely detectable trace of contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against some resistance
5 Active movement against full resistance

BONES: Inspect and palpate SKELETAL structure and tenderness. Specify NOTES
which bone corresponds to findings.
Symmetrical strength gross asymmetry
deformity tenderness
Specify:____________________________________________________

JOINTS. Assess interphalangeal, metacarpophalangeal, wrist, elbow, NOTES


shoulder, metatarsophalangeal, ankles, knees, and hip joints. Specify
which joint corresponds to findings.
symmetrical Bony abnormalities
redness crepitation warmth
swelling tenderness
Specify: ___________________________________________________
Assess Range of Motion of joints (Head to Toe). Specify which joint and
what movement.
Full range of Motion
Specify (joint/movement): ---------------
____________________________________________________________
____________________________________________________________
____________________________________________________________
decreased range of motion
Specify (joint/movement):______________________________________
____________________________________________________________
____________________________________________________________
Others: _____________________________________________________
NEUROLOGICAL ASSESSMENT. Mental status NOTES
Assess speech and language. Briefly describe findings.
Spontaneity__________________________________________________
Ease and enunciation__________________________________________
Sophistication________________________________________________
Check for abnormality.
hesitancy stuttering slurred
aphasia, type_________________________________________
Others_________________________________________________
______________________________________________________
Determine: ORIENTATION – time, place, and person
oriented disoriented specify___________________
Check for LAPSES IN MEMORY. Describe.
Immediate/ short term memory_________________________________
Recent Memory______________________________________________
Remote Memory______________________________________________
Attention Span_______________________________________________
LEVEL OF CONSCIOUSNESS
oriented disoriented specify___________________

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