ScribeAmerica Outpatient Orthopedics
Physical Exam Accurate 100%
What is PE? - ANSWER PE is the objective evaluation of patient's anatomy, physiology
and current function by physician.
Why is PE important? - ANSWER PE information can aid in arriving at final Dx as well
as determine treatment.
5 vital signs - ANSWER Heart rate (HR)
blood pressure(BP)
respiratory rate (RR)
temperature (T)
oxygen saturation (O2 Sat)
Normal General/Constitutional Findings - ANSWER no acute distress (NAD), well
developed, well nourished
Abnormal General/Constitutional Findings - ANSWER -Thin
-Petite
-Cachectic (>poor nutrition)
Normal neck findings - ANSWER Supple, non-tender ROM of the neck
Abnormal Neck findings - ANSWER -Jugular Venous Distension (JVD)
-Tenderness w/ ROM of the neck
-Vertebral point vs. paraspinal tenderness
-Decreased ROM of the neck w/ flexion, extension, rotation and/or lateral bending
Normal Back (T and L spine) findings - ANSWER Nontender thoracic and lumbar spine
Abnormal back (T and L spine) findings - ANSWER -paraspinal tenderness, vertebral
point tenderness
-CVA tenderness
-Vertebral point tenderness
-midline deformities/step-offs
General normal upper extremity findings - ANSWER Non tender full ROM of the
shoulders, elbows, wrists and digits. No gross deformity or joint effusions appreciated
Normal focused exam of the shoulder - ANSWER -No gross deformity or joint effusion
appreciated.
-Non- TTP about the AC and glenohumeral joints.
-No subacromial or glenohumeral crepitus appreciated.
, -Full active non-tender range of motion of the shoulders in
forward flexion, abduction, internal and external rotation.
Abnormal focused exam of the shoulder (2 examples) - ANSWER -Tenderness to
palpation about the acromioclavicular or glenohumeral
joint.
-Crepitus appreciated over the subacromial or glenohumeral joints.
-Positive acromioclavicular joint stress test.
-Positive AC joint subluxation appreciated on stress testing.
-Positive findings on lateral, Hawkin's and/ or Neer's impingement tests.
-Limited range of motion with forward flexion to __ degrees, abduction to__ degrees,
internal rotation to _ degrees, and external rotation to __degrees.
Normal focused exam of the elbow (musculoskeletal) - ANSWER No TTP of the distal
humerus, medial and lateral epicondyle,
or olecranon. Full flexion and extension. Negative Mill's test
Normal focused exam of the elbow (neuro) - ANSWER Neurovascularly intact through
the ulnar, medial, and radial nerve distributions. 5/5 strength with dorsiflexion and
palmarflexion.
Normal focused exam of the hand - ANSWER Full flexion and extension of the fingers,
No joint tenderness,
No tenderness over the anatomical snuff box. No rotational
deformity
Abnormal focused exam of the hand - ANSWER -Tenderness to palpation of the
anatomical snuff box
-Tenderness to palpation over the 1st, 2nd, 3rd, 4th, or 5th
metacarpal
-Extension of the finger limited by X degrees.
-Hyperextension of the thumb
Normal focused exam of the hips - ANSWER No TTP, full flexion and extension, wide
abduction to X
degrees, no click present, symmetric internal and external
rotation.
Abnormal focused exam of the hips - ANSWER -Hip click felt (right, left, or bilaterally)
-Positive Stinchfield, Thomas, Ober, or Trandelenburg's tests
-Leg length discrepancy
-Flexion, extension, abduction, internal/external rotation limited by X degrees
-Asymmetry of the gluteal or inguinal folds
Thomas Test - ANSWER Purpose: Assess fixed flexion deformity of the hip and detects
unilateral hip pathology. {Exaggerated lumbar lordosis --> spine pathology or hip
Physical Exam Accurate 100%
What is PE? - ANSWER PE is the objective evaluation of patient's anatomy, physiology
and current function by physician.
Why is PE important? - ANSWER PE information can aid in arriving at final Dx as well
as determine treatment.
5 vital signs - ANSWER Heart rate (HR)
blood pressure(BP)
respiratory rate (RR)
temperature (T)
oxygen saturation (O2 Sat)
Normal General/Constitutional Findings - ANSWER no acute distress (NAD), well
developed, well nourished
Abnormal General/Constitutional Findings - ANSWER -Thin
-Petite
-Cachectic (>poor nutrition)
Normal neck findings - ANSWER Supple, non-tender ROM of the neck
Abnormal Neck findings - ANSWER -Jugular Venous Distension (JVD)
-Tenderness w/ ROM of the neck
-Vertebral point vs. paraspinal tenderness
-Decreased ROM of the neck w/ flexion, extension, rotation and/or lateral bending
Normal Back (T and L spine) findings - ANSWER Nontender thoracic and lumbar spine
Abnormal back (T and L spine) findings - ANSWER -paraspinal tenderness, vertebral
point tenderness
-CVA tenderness
-Vertebral point tenderness
-midline deformities/step-offs
General normal upper extremity findings - ANSWER Non tender full ROM of the
shoulders, elbows, wrists and digits. No gross deformity or joint effusions appreciated
Normal focused exam of the shoulder - ANSWER -No gross deformity or joint effusion
appreciated.
-Non- TTP about the AC and glenohumeral joints.
-No subacromial or glenohumeral crepitus appreciated.
, -Full active non-tender range of motion of the shoulders in
forward flexion, abduction, internal and external rotation.
Abnormal focused exam of the shoulder (2 examples) - ANSWER -Tenderness to
palpation about the acromioclavicular or glenohumeral
joint.
-Crepitus appreciated over the subacromial or glenohumeral joints.
-Positive acromioclavicular joint stress test.
-Positive AC joint subluxation appreciated on stress testing.
-Positive findings on lateral, Hawkin's and/ or Neer's impingement tests.
-Limited range of motion with forward flexion to __ degrees, abduction to__ degrees,
internal rotation to _ degrees, and external rotation to __degrees.
Normal focused exam of the elbow (musculoskeletal) - ANSWER No TTP of the distal
humerus, medial and lateral epicondyle,
or olecranon. Full flexion and extension. Negative Mill's test
Normal focused exam of the elbow (neuro) - ANSWER Neurovascularly intact through
the ulnar, medial, and radial nerve distributions. 5/5 strength with dorsiflexion and
palmarflexion.
Normal focused exam of the hand - ANSWER Full flexion and extension of the fingers,
No joint tenderness,
No tenderness over the anatomical snuff box. No rotational
deformity
Abnormal focused exam of the hand - ANSWER -Tenderness to palpation of the
anatomical snuff box
-Tenderness to palpation over the 1st, 2nd, 3rd, 4th, or 5th
metacarpal
-Extension of the finger limited by X degrees.
-Hyperextension of the thumb
Normal focused exam of the hips - ANSWER No TTP, full flexion and extension, wide
abduction to X
degrees, no click present, symmetric internal and external
rotation.
Abnormal focused exam of the hips - ANSWER -Hip click felt (right, left, or bilaterally)
-Positive Stinchfield, Thomas, Ober, or Trandelenburg's tests
-Leg length discrepancy
-Flexion, extension, abduction, internal/external rotation limited by X degrees
-Asymmetry of the gluteal or inguinal folds
Thomas Test - ANSWER Purpose: Assess fixed flexion deformity of the hip and detects
unilateral hip pathology. {Exaggerated lumbar lordosis --> spine pathology or hip
