Monday, April 18, 2016

Step 2 CS: Musculoskeletal patient note

IPROM MRSP is a brilliant mnemonic
You can use it for patient notes as well!

For shoulder pain:
Inspection - R arm is closely held to the chest wall. R shoulder appears red compared to the L.
Palpation - Non localized tenderness on palpation of R shoulder, arm and clavicle.
ROM - Pain and restricted flexion, extension, abduction, adduction, internal rotation and external rotation.
Motor - Unable to assess strength due to pain.
DTR's - 2+ intact, symmetric (If time, mention - Biceps, triceps and supinator)
Sensations - Intact to pin prick and light touch
Pulses - 2+ in brachial and radial arteries

For wrist pain:
Palpation - Non tender to palpation
ROM - Flexion, extension, abduction, adduction are WNL
Motor - 5/5 strength in shoulder, elbow and wrist
DTR's - 2+ intact, symmetric
Sensations - Intact to pin prick and light touch except decreased sensation in the palmar aspect of right arm
Pulse - 2+ in brachial and radial arteries
Tinels, Phalens test +ve. Finkelsteins test -ve.

For knee pain:
Inspection - L knee looks red compared to R
Palpation - Non tender to palpation
ROM - WNL
Motor - 5/5 strength in hip, knee and foot
DTR's - 2+ intact, symmetric
Sensation - Intact to pin prick and light touch
Pulses - 2+ in popliteal and dorsalis pedis arteries
Mc Murray, anterior and posterior drawer test, varus and valgus stress test are negative.

For heel pain:
Inspection - No evidence of trauma
Palpation - Tender to palpation on medial calcaneal tuberosity and plantar fascia
ROM - WNL
Motor - 5/5 strength in hip, knee, foot and toe
DTRs - 2+ intact, symmetric
Sensations - Intact to pin prick and light touch
Pulses - 2+ in posterior tibial and dorsalis pedis arteries
Heel and arch pain on dorsiflexion of great toe.


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