1. Physical Examination Findings
General
Conscious, coherent, wheelchair-borne, not in cardiorespiratory distress
Vital Signs
BP: 110/70 (right and left arm, seated)
PR: 79 beats/min,regular
RR: 19 breaths/min, regular
Temp: not assessed

2. Measurements
Height: not assessed
Weight: not assessed
BMI: not assessed
Skin
Dry skin, No skin discolorations, No skin lesions

3. HEENT
Normocephalic, no facial asymmetry
Normal eye position and alignment, hyperemic sclera, pink conjunctiva, no corneal and lens opacities, no exudates
No ear deformities, lesions, nodules, discharge, odor, swelling, redness, foreign bodies, (+) dry cerumen
Nose and throat not assessed

4. Chest and Lungs
Not assessed
Heart
Abdomen

5. Extremities Brachial Radial Femoral Popliteal Posterior Tibia
Dorsalis Pedis
Right ++
Regular
Not assessed +
Left
(0) = absent (+) = decreased (++) = normal (+++) = hyperactive (Br) = bruit

6. Musculoskeletal Examination
Cervical Spine
Inspection
No skin changes, no swelling, no deformities
Range of Motion
Active
Passive
Flexion
Normal
Extension
Side Flexion (right and left)
Rotation (right and left)
Palpation
No palpable nodules, no tenderness

7. Musculoskeletal Examination
Shoulder Joint
Range of Motion
Active
Passive
Forward flexion (right and left)
Normal
Extension (right and left)
Not assessed
Abduction (right and left)
Limited
Internal and external rotation (right and left)
None
Palpation
No palpable nodules, no tenderness

8. Musculoskeletal Examination
Forearm
Inspection
No skin changes, no swelling, no deformities
Range of Motion
Active
Passive
Pronation
Normal
Supination
None – Left side
Limited – Right side
Palpation
No palpable nodules, no tenderness

9. Musculoskeletal Examination
Wrist
Inspection
No skin changes, no swelling, no deformities
Range of Motion
Active
Passive
Flexion
Limited
Extension
Ulnar deviation
Radial deviation
Palpation
No palpable nodules, no tenderness

10. Musculoskeletal Examination
Inspection
Active Movement
Passive Movement
Left Hand
Boutonniere’s deformity on all fingers
Can make a fist (flexion at MCP)
Finger abduction : thumb and index
Finger adduction: thumb and index
(-) extension at MCP on all fingers
(-) flexion/extension at PIP and DIP
Thumb: flexion/extension at MCP
Index: flexion/extension at MCP
Middle: flexion/extension (limited) at MCP
Ring: flexion/extension (limited) at MCP
Little: flexion at MCP
Right hand
Boutonniere’s deformity – thumb, middle, ring
Swan neck deformity – index, little finger
Middle: flexion at MCP
Ring: flexion at MCP
Little: flexion at MCP

11. Musculoskeletal Examination
Knees
Inspection
Swelling of both knees
Range of Motion
Active
Passive
Flexion
Normal
Extension
None
Limited
Palpation
No palpable nodules, no tenderness

12. Musculoskeletal Examination
Ankle joint and foot
Inspection
No deformities
Range of Motion
Active
Passive
Plantar Flexion
Normal
Dorsiflexion
Inversion
Eversion
Toe extension
Toe flexion
Palpation
No palpable nodules, no tenderness

13. Neurologic Examination
CN II: (+) Red-orange reflex
CN VIII: Rinne (+), Weber – no lateralization