Hands

#Hands

S: Subjective

Side examined: right**left

Presenting Complaint:

O: Objective

Examination:
Normal ranges are in [square brackets].

Two-point discrimination test:
< 7 mm = nil sensory loss
7-15 mm = partial sensory loss
> 15 mm = total sensory loss

Thumb:

1. Motion (measured in degrees using a goniometer)

IP joint: 
- Flexion: 
- Extension: 
- Ankylosis: 
MP joint: 
- Flexion: 
- Extension: 
- Ankylosis: 
CMC Joint:
- Radial abduction
  - Motion: 
  - Ankylosis: 
- Adduction
  - Motion: 
  - Ankylosis: 
- Opposition
  - Motion: 
  - Ankylosis:

2. Amputation

Level of amputation:

3. Sensory loss

Ulnar digital nerve:
- Two-point discrimination loss: 
- % digit length involved: 
Radial digital nerve:
- Two-point discrimination loss: 
- % digit length involved:

4. Other findings: ?

Index finger:

1. Motion (measured in degrees using a goniometer)

DIP joint: 
- Flexion: 
- Extension: 
- Ankylosis: 
PIP joint: 
- Flexion: 
- Extension: 
- Ankylosis: 
MP Joint:
- Flexion: 
- Extension: 
- Ankylosis:

2. Amputation

Level of amputation:

3. Sensory loss

Ulnar digital nerve: 
- Two-point discrimination loss: 
- % digit length involved: 
Radial digital nerve: 
- Two-point discrimination loss: 
- % digit length involved:

4. Other findings:

Middle finger:

1. Motion (measured in degrees using a goniometer)

DIP joint: 
- Flexion: 
- Extension: 
- Ankylosis: 
PIP joint: 
- Flexion: 
- Extension: 
- Ankylosis: 
MP Joint:
- Flexion: 
- Extension: 
- Ankylosis:

2. Amputation

Level of amputation:

3. Sensory loss

Ulnar digital nerve: 
- Two-point discrimination loss: 
- % digit length involved: 
Radial digital nerve: 
- Two-point discrimination loss: 
- % digit length involved:

4. Other findings:

Ring finger:

1. Motion (measured in degrees using a goniometer)

DIP joint: 
- Flexion: 
- Extension: 
- Ankylosis: 
PIP joint: 
- Flexion: 
- Extension: 
- Ankylosis: 
MP Joint:
- Flexion: 
- Extension: 
- Ankylosis:

2. Amputation

Level of amputation:

3. Sensory loss

Ulnar digital nerve: 
- Two-point discrimination loss: 
- % digit length involved: 
Radial digital nerve: 
- Two-point discrimination loss: 
- % digit length involved:

4. Other findings:

Little finger:

1. Motion (measured in degrees using a goniometer)

DIP joint: 
- Flexion: 
- Extension: 
- Ankylosis: 
PIP joint: 
- Flexion: 
- Extension: 
- Ankylosis: 
MP Joint:
- Flexion: 
- Extension: 
- Ankylosis:

2. Amputation

Level of amputation:

3. Sensory loss

Ulnar digital nerve: 
- Two-point discrimination loss: 
- % digit length involved: 
Radial digital nerve: 
- Two-point discrimination loss: 
- % digit length involved:

4. Other findings:

A: Assessment

Clinical Summary:

Diagnosis / DDx:

P: Plan

Investigations:

Treatment:

Referrals:

Patient Education / Home Care Advice:

Review:

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Hands

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