Health History Questions
-Past Medical History: Questions related to: Past injuries, surgery,
PQRST Questions
Objective Data Types
INSPECTION
PALPATION & STRENGTH:
Musculoskeletal - Age Related
Changes (Older Adults)
Muscle Strength - Face and
Neck
Present Health Status
Trauma, Fractures, Dislocations, Sprains, Age, Congenital defects?
-Family History: Questions related to: Cancer, MS, Back problems
What provokes or worsens you pain? What relieves or causes the
pain to subside?
What does the pain feel like?
Where is the pain? Does the pain radiate to other parts of your body?
How severe is your pain? How would you rate it on a scale of 1-10?
How would you describe the intensity of your pain?
When did the pain begin? At what time of day is your pain
best/worst? Is the onset sudden or gradual? Is the pain constant or
intermittent?
OBJECTIVE DATA
*Examination (should include...)
- Inspection - For body strength & symmetry
- Palpation - For muscle tone, pain, heat or edema
- Muscle Strength - Body ROM, strength & resistance
Check for deformities or obvious injuries; Body shape and symmetry;
Posture; Alignment; Gait; Balance; Movement; Coordination
TESTS INCLUDE: Heel 2 Toe walk; Romberg Test (Arms at side, feet
together, eyes closed, Check for balance for 20 seconds); Heel of one
foot down the shin of another.
Symmetry of muscles & joints (will be slightly stronger on dominant
side); Tone, Pain, Heat(Use Dorsal side of hand to feel for heat),
Edema (No redness or swelling)
- Muscle Strength & resistance; ROM (range of movement)
TESTS INCLUDE STRENGTH & RESISTANCE & ROM: Palpations
(starting at shoulders using palms of hands to check for symmetry,
joint swelling and pain when squeezed); Pushes & Pulls (for muscle
strength symmetry) - Place hands on shoulders as patient shrugs,
have patient squeeze your thumbs; SPINE CURVATURE (Have patient
bend over as far as comfortable and run hands up spine for curvature
and alignment); Alignment of iliac crest and scapula; Free motion
(pain or crepitus - popping of joints during movement); TMJ (jaw);
Strength in feet
*IF THERE IS ROM RESISTENCE OR PAIN - STOP THE ASSESSMENT!
Decrease in bone mass
* Muscle Weakness
* Atrophy of muscle for disuse
* Decreased ROM (will affect ADL's)
palpate TMJ (front of each ear) for movement, sounds and
tenderness: move jaw from side to side; palpate Head and neck

Muscle Strength - Arms
strength
- check resistance against nurses hand, side to side and back and
front - ear to shoulder
have client hold arms out while your try to push them down - have
client put arms in fight position the push and pull on nurse - palpate
for crepitus, pain, heat, tenderness and edema

Muscle Strength - Shoulders and Spine
Muscle Strength - Wrist, Hand &
Fingers
Muscle Strength - Hips
Muslce Strength - Knees, Ankle, Foot &
Toes
Flexion
Inspect shoulders and spine for alignment and symmetry- have
client touch toes - have client bend and waist, side to side and
back to front - palpate spine for tenderness or displacement -
have client shrug shoulders while nurse attempts to push down
palpate for heat, tenderness, edema, pain - ROM exams include:
WRIST: (Hyperextension)Bring dorsal surface of hand back as far
as possible (Flexion) Move palm toward inner aspect of forearm,
(Extension) Move fingers and hand posterior to midline.
(Abduction) Place hand w/ palm down and extend wrist laterally
toward fifth finger (Adduction) Place hand w/ palm down and
extend wrist medially toward thumb. FINGERS: (Flexion) Make
fist (Hyperextension) Bend fingers back as far as possible.
(Abduction) Spread fingers apart and bring together. THUMB:
(Flexion) Move thumb across palmar surface of hand.
(Extension) Move thumb straight away from hand. (Adduction)
Move thumb back toward hand (Opposition) touch thumb to
each finger of same hand.
palpate for tenderness, edema *HIPS: (Flexion)Move leg
forward and up (Extension) Move back beside other leg
(Hyperextension)Move leg behind body. (Abduction) Move leg
laterally away from body (Adduction) Move leg back toward
medial position and beyond if possible (Internal Rotation) Turn
foot and leg toward other leg (External Rotation)Turn foot and
leg away fromn other leg .(Circumduciton) Move leg in a circle
palpate for tenderness, edema KNEES: (Flexion)Bring heel back
toward back of thigh (Extension)Return leg to floor, ANKLE:
(Dorsal Flexion) Move foot so that toes are pointed upwards,
(Plantar Flexion) Move foot so that toes are pointed
downward. FOOT: (Inversion) Turn sole of foot medially,
(Eversion) Turn sole of foot laterally. TOES: (Flexion) Curl toes
downward, (Extension) Straighten toes (Abduction) Spread toes
apart (Adduction) Bring toes together.
Movement decreasing angle between 2 adjoining bones;
bending of limb.

Extension Movement increasing angle between 2 adjoining bones.

Movement of body part beyond its normal resting extended

Hyperextension position
Movement of body part so that front or ventral surface faces
downward.
Pronation Movement of body part so that the front or ventral surface faces
upward.

Supination Movement of extremity away from midline of body

Abduction Movement of extremity toward midline of body
Adduction Rotation of joint inward
Internal Rotation Rotation of joint outward
External Rotation Turning of body part away from midline
Eversion Turning of body part toward midline
Inversion Flexion of toes and foot upward
Dorsiflexion Bending of toes and foot downward
Plantar Flexion
 MUSCULOSKELETAL ASSESSMENT

SUBMITTED BY:

CARYL CAYABYAB

SLU-BSN III-A4

SUBMITTED TO:

JEFFERSON GALANZA