The Essentials of Documenting an Extremity Exam

Today, we’re continuing our series on documentation with the extremities. From orthopedic injuries, to infection, and symptoms of systemic illness, there’s a wide range of findings you may note on an exam of the upper and/or lower extremities. Documenting these findings appropriately is important not only to the continuity of care for your patient, but also to protect yourself legally as a provider and justify your treatment plan. So, how do you document an extremity exam?

What You’re Looking For

An extremity exam may be done in the case of trauma, for example, an injury to the knee or ankle. It may also reveal other abnormalities, such as signs of a vascular problem like a deep vein thrombisis, or signs of infection, such as a septic joint. To adequately assess an extremity, you must include the following exam components: 

1. Inspection – Examine the extremities for deformity, skin abnormalities, size, length, shape, position, symmetry, swelling etc. 
2. Palpation – Assess extremities for tenderness, soft tissue swelling, and joint effusions. Don’t forget to assess vasculature by examining capillary refill and palpating pulses. Also note sensation as you palpate the extremities. 
3. Range of Motion – Test the range of motion of each joint in each direction. Note any abnormalities. 
4. Muscle Strength and Tone – Check muscle strength of the extremities, grading strength on a scale of 0 to 5. 
5. Gait – Include any observations about the patient’s gait in your exam. Note if you are unable to test gait related to pain. 

Buzzwords to Know

There are numerous tests that help with the examination of joints, such as the knee and shoulder, to help identify the pathology causing the patient’s problem. Given the large number of such tests, we won’t discuss them in detail here. There are, however, a few words you may run into in extremity documentation that are essential to know. 

• Antalgic Gait – An antalgic gait occurs when the patient avoids bearing weight on one leg due to pain. The patient bears weight for the shortest possible amount of time on the affected extremity. 
• Compartment Syndrome – A serious condition that can occur when excessive tissue pressure builds up in a muscle compartment and typically results from bleeding and swelling after an injury. Compartment syndrome can cause decreased perfusion to the affected extremity and is a medical emergency. Always document that you have checked for signs of compartment syndrome when documenting an extremity injury. 

Sample Normal Exam Documentation

Documentation of a basic, normal extremity exam should look something along the lines of the following: 

Extremities are atraumatic in appearance without tenderness or deformity. Extremities are without swelling or erythema. Full range of motion is noted to all joints. Muscle strength is 5/5 biaterally. Tendon function is normal. Capillary refill is less than 3 seconds in all extremities. Pulses palpable. Steady gait noted. 

Sample Abnormal Exam Documentation

When documenting an abnormality on an extremity exam, be as specific as possible as to where the abnormality lies. Words like upper, lower, distal, proximal, lateral, and medial may be helpful in documenting the location of your findings. 

While you won’t use all of these items in a single exam, the following are some extremity abnormalities you may want to note. Abnormals on an extremity exam may include: 

• Tenderness 
• Deformity
• External skin changes such as erythema, ecchymosis, abrasion, laceration, skin tear, puncture wound, scarring, or warmth
• Foreign body (visible or palpable)
• Joint instability, dislocation, subluxation, or laxity
• Decreased muscle strength or tone (ex. flaccid, atrophy)
• Joint effusion
• Swelling
• Crepitus
• Decreased sensation
• Limited range of motion and/or abnormal movements
• Abnormalities of tendon function
• Masses (visible or palpable, size, shape, location)
• Gait changes (limping, antalgic)
• Ability to bear weight
• Perfusion (sluggish capillary refill, bounding pulses, diminished or absent pulses)
• Edema

**Note: This is not a comprehensive guide. You are responsible for performing an appropriate physical exam and documenting your findings on each and every patients you interact with. 

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