Documentation of Examination
This may be used as a template or example of what you may want to include in the documentation of your elbow exam. See below to download a PDF version of the documentation for printing.
Inspection:
Documentation of symmetry, atrophy. (Absence/presence) of elbow effusion, ecchymosis, swelling, deformity or defect.
Range of motion of the elbow:
Flexion to (xx degrees or full). Extension to (xx degrees or full) supination and pronation (xx degrees or full)
Palpation:
(Tenderness/no tenderness) to palpation of (specific areas or landmarks such as olecrenon, medial or lateral epicondyle, radial head, biceps tendon in antecubital fossa, and location of posterior interosseus nerve)
Specific Testing:
(Tenderness/no tenderness) over MCL. (Laxity/no laxity) of the MCL with valgus at 0 degrees, 30 degrees (Tenderness/no tenderness) over LCL (Laxity/no laxity) of the LCL with varus at 0 degrees, 30 degrees (Positive/Negative) Cozen's test (Positive/Negative) Maudsley's test (Positive/Negative) Tinel's test of the cubital tunnel
Neurovascular Exam:
Document radial and ulnar artery pulses and capillary refill. Sensory exam. Brief neurologic exam for motor function could include resisted wrist extension for radial nerve, resisted opposition of the thumb for the median nerve and resisted digit abduction for the ulnar nerve.