Writing Up the Physical Examination

Listed here are examples of the write-up for the examination of the musculoskeletal system.

• All the joints have full range of motion. No deformities, tenderness, or abnormalities are detected.

• There is marked ulnar deviation of both hands in association with a flexion deformity of all the proximal interphalangeal joints and hyperextension of all the distal interphalangeal joints. Marked tenderness of both wrists is present.

• There is abnormal forward mobility of the knee. There is 3 to 4 cm of motion detected.

• The left first metatarsophalangeal joint is markedly erythematous and painful. The joint is shiny and edematous.

• No joint deformities are noted. There is marked reduction of hip internal and external rotation. No pain is produced by these movements. Pain is produced by abduction of the right shoulder against resistance. The range of right shoulder abduction is reduced. The range of motion of the hands, wrists, spine, knees, and ankles is normal.

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