Elbow Regional Examination Patient:____________________________________ date: ______ Check normal, circle & describe abnormal (dd/mm/yr) CC & signifi cant history: ____________________________________________________ Insurance: ______________________________________ __________________________________________________________________________ Date of birth: ____________________________________ M/F Fracture screen (tuning fork, percussion, torsion test, grip strength): □ WWNLNL, □ RReferefer fforor XX-ra-ray: _________________________________________ Observation: □ WWNLNL Palpation: □ WWNL,NL, texture, tenderness, pain referral Development: □ ggood,ood, □ ffair,air, □ ppooroor RRightight LLefteft □ AAntalgia:ntalgia: __________________________________________________ Palpation L R Palpation L R □ SSkinkin ((bruising,bruising, sscars):cars): ______________________________ Medial epicondyle Common exten. tendon □ AAsymmetry:symmetry: ______________________________________________ Ulnar groove Anconeus Observation □ WNL L R Med. collateral ligament Brachioradialis Common fl exor tendon Extensor carpi ulnaris Head tilt Flexor carpi ulnaris Extensor carpi rad longus Head rotation Palmaris longus Extensor carpi rad brevis Shoulder high Flexor carpi radialis Extensor digitorum Shoulder rounded Pronator teres Supinator Humerus rotated Biceps tendon Triceps tendon Elbow fl exed Head of radius Triceps muscle Elbow hyperextended Radial tunnel Olecranon Valgus forearm Lateral epicondyle Olecranon bursa Varus forearm Lat. collateral ligament Cubital fossa Forearm pronated Lat. supracondylar ridge Brachialis Forearm supinated ________________________________________________________________________________________________________________________________________________________________ Hand/fi nger deformity ________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ____________________________________________________________________________________ Neurologic: □ WWNLNL Orthopedic: □ WWNLNL Refl exes (0-5), □ WNL L R Instability L R Lateral epicondylitis LR Vascular Screen: □ WWNLNL Biceps (C5) Valgus stress (0°) Book lift test Pulses (0-4) L R Brachioradialis (C6) Valgus stress (30°) Cozen’s Brachial pulse Triceps (C7) Varus stress (0°) Mill’s Radial pulse General grip strength Varus stress (30°) Kaplan’s test Ulnar pulse Motor (0-5), □ WNL L R Blanch test Medial epicondylitis LR Neuropathy L R Shoulder fl exors Allen’s test Reverse Cozen’s Tinel’s (elbow) Shoulder extensors Temperature Reverse Mill’s Tinel’s (wrist) Biceps brachii (musc.) Reverse book lift Elbow fl exion test Brachialis (musc.) Pronator stretch test ROM & Joint Play: □ WWNLNL Brachioradialis (radial) □ PPainain aatt eendnd RROM:OM: ____________________________________ Triceps brachii (radial) Dynamometer L R L R L R □ AAbnormalbnormal mmotion:otion: ____________________________________ Wrist extensors (radial) Repeat 3 times Wrist fl exors (median/ulnar) Active Passive Serial #_______________________ Setting: ________________ ROM Wrist abductors (median/radial) __________________________________________________________________________________________ LRLR Wrist adductors (ulnar/radial) __________________________________________________________________________________________ Flexion (150°) Pronator teres (median) ________________________________________________________________________________________________ Extension (0°) Supinator (radial) ______________________________________________________________________________________________ Supination (90°) Finger fl exors (median/ulnar) __________________________________________________________________________________________ Pronation (90°) Finger extensors (radial) NNeckeck eevaluation:valuation: ____________________________________________________________________ SShoulderhoulder eeval:val: ________________________________________________________________________ Joint Play L R Girth*, □ WNL L R WWrist/handrist/hand eeval:val: ________________________________________________________________ Ulnohumeral Mid arm Elbow Radiohumeral DDx: _____________________________________ Proximal radioulnar Mid forearm _____________________________________________ Carrying angle ______________________________________________________________________ _______________________________________________ ______________________________________________________________________ **Atrophy,Atrophy, sswelling,welling, ddominantominant vvs.s. nnon-dominanton-dominant ______________________________________________ ***General*General seensationnsation iiss ddoneone tthroughhrough ppalpationalpation This form is a comprehensive checklist of examination procedures. Each item should be utilized as a diagnostic option based on the patient’s presenting symptoms and the clinical discretion of the examiner. Every procedure does not have to be performed on every patient. Some procedures may be Signature: Date: contraindicated in certain situations. Patient information contained within this form is considered strictly confi dential. Reproduction is permitted for personal use, not for resale or redistribution. www.prohealthsys.com ©2005 by Professional Health Systems Inc. All rights reserved. “Dedicated to Clinical Excellence.”.