Telehealth Shoulder
Examination
Constitutional:
Height and weight as reported by
patient Well developed, well nourished
No apparent distress
Neuro/Psych:
Oriented to person, place, and time
Mood: Normal
Affect: Normal
Skin:
No observed rashes right upper extremity
No observed rashes left upper extremity
Musculoskeletal
Balance and coordination: Normal
Musculoskeletal Gait normal antalgic
Requires aide cane, crutches, walker
Transfer: arising from the seated position independently
Right shoulder exam
*All documented physical exam maneuvers have been modified from their original
medical descriptions for the purposes of telehealth examination
Inspection: No swelling, ecchymosis or gross deformity.
Skin: Y/N masses, Y/N lesions, (incisions for postop patients Y/N clean dry and
intact) Tenderness (as demonstrated by provider and reported by patient):
Y/N bicipital groove tenderness
Y/N tenderness to the greater tuberosity/RTC
insertion Y/N anterior shoulder/lesser tuberosity
tenderness.
Y/N tenderness SC joint
Y/N tenderness clavicle
Y/N tenderness AC
joint.
ROM: (as demonstrated by provider and performed by
patient) Forward elevation
Abduction
External rotation with arm at side
Internal rotation
Impingement tests (as demonstrated by provider and performed by patient): pos/neg
Neer
AC Joint (as demonstrated by provider and performed by patient): Y/N pain with cross
arm testing
Biceps (as demonstrated by provider and performed by patient): positive/neg speed
Examination
Constitutional:
Height and weight as reported by
patient Well developed, well nourished
No apparent distress
Neuro/Psych:
Oriented to person, place, and time
Mood: Normal
Affect: Normal
Skin:
No observed rashes right upper extremity
No observed rashes left upper extremity
Musculoskeletal
Balance and coordination: Normal
Musculoskeletal Gait normal antalgic
Requires aide cane, crutches, walker
Transfer: arising from the seated position independently
Right shoulder exam
*All documented physical exam maneuvers have been modified from their original
medical descriptions for the purposes of telehealth examination
Inspection: No swelling, ecchymosis or gross deformity.
Skin: Y/N masses, Y/N lesions, (incisions for postop patients Y/N clean dry and
intact) Tenderness (as demonstrated by provider and reported by patient):
Y/N bicipital groove tenderness
Y/N tenderness to the greater tuberosity/RTC
insertion Y/N anterior shoulder/lesser tuberosity
tenderness.
Y/N tenderness SC joint
Y/N tenderness clavicle
Y/N tenderness AC
joint.
ROM: (as demonstrated by provider and performed by
patient) Forward elevation
Abduction
External rotation with arm at side
Internal rotation
Impingement tests (as demonstrated by provider and performed by patient): pos/neg
Neer
AC Joint (as demonstrated by provider and performed by patient): Y/N pain with cross
arm testing
Biceps (as demonstrated by provider and performed by patient): positive/neg speed
