INSTITUTE OF NURSING EDUCATION, MUMBAI
MEDICAL SURGICAL NURSING - I
MUSCULOSKELETAL SYSTEM ASSESSMENT FORMAT
Patient's Bio Data
1. Name –
2. Age – 3. Gender –
4. Height – 5. Weight –
6. Education – 7. Occupation –
8. Address –
9. Ward –
10. Diagnosis –
History
1. Present History –
a. Area of pain –
b. Onset - Insidious Onset / Traumatic Onset
c. Duration - Acute / Chronic. Mention Time - __________________
d. Severity –
e. Nature of pain - Sharp / Aching / Throbbing / Dull / Burning / Tingling / Shooting / Electric
shock-like
f. Type of pain - Nociceptive pain / Neuropathic pain / Referred pain / Allodynia /
Hyperalgesia.
g. Aggravating Factor –
h. Relieving Factor –
i. Accompanying symptoms – Swelling / Redness / Tenderness / Numbness / Heaviness /
Paraesthesia / Pallor / Pulselessness / Warmth / Coldness / Fever / any other - ____________.
j. Does pain affect the activity of daily living? Yes / No. If Yes, describe - ________________.
2. Past History –
a. Medical History –
i. Known case of – Hypertension / Diabetes / Cardiovascular diseases / Cerebrovascular
Diseases / Neurological Disorders / Blood Coagulation disorders / Peripheral Vascular
Diseases / Rheumatic Arthritis / Others - ___________________________________.
ii. Medications prescribed for the same –
Sr. Name of the Frequency Duration
Dose (OD / BD / TID/ HS / Occasionally Since when the drugs
No medication
when symptoms erupts) are used ?
b. Orthopaedic history –
i. Known case of - Osteoporosis / Sprain / Ligament Tear / Tendon Tear / Meniscus Tear
/ Fracture – Mention Site ________________ / Other - ___________________.
ii. Orthopaedic conditions were managed by – Medication / Corrective Surgery /
Physiotherapy / AYUSH / Other therapies. Specify - __________________________.
____________________________________________________________________.
c. Surgical History –
i. Has the patient undergone any major surgical procedures in recent times – Yes / No.
If yes, specify - _______________________________________________ .
ii. Was the patient immobilised for a long period – Yes / No
If yes, specify the site of immobilisation and duration - ____________________.
d. Other history –
i. History of congenital musculoskeletal anomalies – Present / Absent.
If present, specify - ___________________
If present – Corrected / Not Corrected.
If Corrected, Specify method - _________________________.
ii. Polio Vaccination – Completed / Not Completed
e. Social History –
i. Smoking – Yes / No
If Yes – Regular / Intermittent.
Mention no. of cigarettes per day and since when - _______________.
ii. Alcoholic – Yes / No.
If yes – Regular / Intermittent
Mention the quantity and from since when - ____________________.
iii. Any other adductive used – Yes / No
If yes, Specify - ______________, Duration - __________, Quantity - _________.
f. Working / Job-related history –
i. Occupation - _______________________.
ii. Involved in hazardous activity – Yes / No.
iii. Do you know about Personal Protective Equipment – Yes / No
iv. Is the Personal Protective Equipment available and used regularly? ______________.
Physical Examination
1. General appearance –
a. Built – Thin and Lean / Muscular / Fatty or Obese
b. Posture – Neutral / Kyphotic / Lordosis / Flat Back / Forward Head / Sway Back / Scoliosis
c. Gait – Antalgic Gait / Ataxic Gait / Hemiplegic Gait / Parkinsonian Gait / Steppage Gait /
Scissor Gait / Waddling Gait / Propulsive Gait / Trendelenburg Gait / Stuttering Gait / Tabetic
Gait / Choreatic Gait
d. Balance – Static and Dynamic -
Position Eyes Open Eyes Closed
Sitting
Standing
Tandem Standing
Reaching activity
e. Coordination test –
i. Equilibrium test –
Test Grade
Standing in normal Posture
Standing with feet together
Standing on one foot
Standing with lateral trunk flexion
Walking sideways
Walking Backwards
Walking in a circle
Walking on heels
Walking on toes
ii. Non-Equilibrium Test –
Test Right Left
Finger to toe
Finger Opposition
Mass grip
Pronation Supination
Tapping Hand
Tapping Foot
Heel to Knee
Drawing Circle with hand
Drawing circle with foot
f. Body Symmetry – Symmetrical / Asymmetrical
g. Personal Hygiene and Grooming – Adequately maintained by self / Maintained with help of
partial Assistant / Unable to maintain without complete assistance / Completely dependent on
assistance
h. Use of Mobility Aids – Yes / No.
If Yes, specify – Canes or Walking Stick / Crutches / Walkers / Wheelchair / Prosthetic and
Orthopaedic devices / Robotic aids or Exoskeleton / Others, Specify - __________________.
2. Vital Signs –
a. Temperature - __________ d. Blood Pressure - ______________
b. Pulse - _____________. e. SPO2 - ________________.
c. Respiratory Rate - ___________.
3. Orthopaedic Assessment –
a. Range of Motion Assessment – Sitting / Standing / Lying
Joint Motion Active / Passive Limitation
Neck
Vertebral
1. Cervical
2. Thoracic
3. Lumbar
Shoulder
Elbow
Wrist
Fingers
Hip joint
Knee
Ankle
Foot
Toe
Inferences -
___________________________________________________________________________
___________________________________________________________________________
b. Strength Assessment –
Muscles of MRC Scale for Muscle Strength Score Inferences
Neck region
Vertebral region
1. Cervical
2. Thoracic
3. Lumbar
Shoulder region
Elbow region
Wrist region
Fingers
Hip region
Knee region
Ankle region
Foot region
Toes
The Medical Research Council (MRC) Scale for Muscle Strength
Score Grading
0 No muscle activation
1 Trace muscle activation, such as a twitch, without achieving full range of motion
2 Muscle activation with gravity eliminated, achieving full range of motion
3 Muscle activation against gravity, full range of motion
4 Muscle activation against some resistance, full range of motion
5 Muscle activation against examiner’s full resistance, full range of motion
c. Reflexes –
Reflexes Left Right
Superficial Abdominal
Plantar
Deep Biceps
Brachioradialis
Triceps
Knee
Ankle
d. Sensory Assessment –
Location Upper Extremity Lower Extremity Trunk
Type of Right Left Right Left Right Left
Sensation
Pain
Heat
Cold
Touch
Pressure
4. Orthopaedic palpation –
a. Superficial Palpation – (Done at the site of pain to assess Swelling, Tenderness, Texture and
Temperature, effusion, enlargement)
Findings -
___________________________________________________________________________
___________________________________________________________________________
b. Deep palpation – (Done to assess the structures like muscles, tendons, ligaments abd bony
landmarks)
___________________________________________________________________________
___________________________________________________________________________
c. Passive Intervertebral Motion Palpation –
___________________________________________________________________________
___________________________________________________________________________
Investigation
1. X-ray findings -
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2. CT scan findings -
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. MRI findings -
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. Bone density findings -
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
