Musculoskeletal System Analysis

Documentation Form Student Name:___________ Health Assessment Score: ____/2pts. Nursing 210 System: Musculoskeletal System Subjective Findings: Review Health History ** Follow guidelines on prior documentation forms Chief Complaint: History of Present Illness: Past Medical History: Family History: Personal and Social History: Objective Findings: Inspection/Palpation *Skeleton and joints *symmetry *skin color *edema *lesions *skin temperature *size *contour *deformity *masses *tenderness Range of Motion: List movements for each joint *temporomandibular *cervical spine *shoulder *elbow *wrist *hand/fingers *hip *knee *ankle *feet *toes Muscle Strength: *head and neck *upper extremities *lower extremities Student Name: _______________ Cranial Nerve I Olfactory II Optic III Occulomotor IV Trochlear VI Abducens V Trigeminal VII Facial VIII Acoustic IX Glossopharygeal X Vagus XI Spinal Accessory XII Hypoglossal Examination Expected Response Motor System Balance Examination Gait Romberg Knee bend Coordination Rapid Alternation Movement (RAM) Rapid finger to finger/nose Heel to shin Sensory Function Light Touch Superficial Pain Deep Tendon Reflexes (Patellar) Superficial Reflexes (Babinski) Expected Response …