ComprehensiveClinicalCases

Orthopedic case proformas

1. Pathological joints/Osteoarthritis

Patient particulars

Name
Age
Gender
Address
Education
Occupation
Date of admission.
Date of examination

Chief complaints:
Pain
Joint Swelling
Joint stiffness
Restricted movement
Deformity.
Joint involved

History of present illness.

Pain
Joints involved-small/Large
Nature of pain
Joints involved -Symmetrical/Asymmetrical/Fleeting type of Joint pain
Onset
Duration
Progression
Diurnal variation
Aggravating factor
Reliving factors

Joint stiffness
Onset
Duration
Progression
Early morning stiffness
Diurnal variation
Aggravating factor
Reliving factors
Associated symptoms like pain etc

Restricted movement
E.g. Difficulty in squatting (osteoarthritis of Knee)

Joint swelling
Onset
Duration
Progression
Joints involved-Large/small
Symmetrical /asymmetrical
Number of joints involved
Involvement of small and large joints
Associated symptoms :fever, jointstiffness, painful movement.
Associated symptoms of other systemic illnesses

Joint deformity
Joints involved-Large/small
Symmetrical or asymmetrical
Number of joints involved
Restricted movement
Associated symptoms like pain ,fever.

Locking.

Past history.
Similar illness in the past
Any diagnosed joint diseases
Any other diagnosed systemic illnesses
Diabetes mellitus,tuberculosis,other illnesses like gonorrhea,syphilis,pneumonia
etc

Treatment history

Menstrual history (In females)

Marital and obstetric history (Females)

Family history.
Similar illness in the family .
Haemophilia,Tuberculosis,gout,rheumatism etc

Socioeconomic history

Environmental history.

General physical examination.

Patient is conscious, cooperative
Oriented to Time place and person.
Built
Nourishment
Gait

Vitals:

Pulse
Blood pressure
Respiration
Temperature.

Pallor
Icterus
Cyanosis
Clubbing
Edema
Lymphadenopathy
Height
Weight
BMI
Head to toe examination.
Local examination.
Inspection.
Swelling
Deformity and position of the joint.
Skin over the joint
Muscular wasting

Palpation.
Local rise of temperature
Tenderness
Palpation of bony component
Swelling
Muscular wasting

Movements.

Measurements

Auscultation in case crepitus is present.

Examination of the lymph nodes

Systemic examination
Cardiovascular system

Respiratory system

Abdomen

Central nervous system

Summary.

Provisional diagnosis

Differential diagnosis.

Investigation

Treatment.
2.Peripheral nerve lesions(Nerve injury)

Patient particulars

Name
Age
Gender
Address
Education
Occupation
Date of admission.
Date of examination

Chief complaints:
Inability to move limbs/Restricted movements
Loss of sensation

History of present illness .

Restricted movement/Inability to move the limbs.

Limbs or part of the limb involved
To what extent
Onset
Duration
Progression
Associated symptoms

Pain
Onset
Duration
Progression
Nature of pain
Aggravating factors
Reliving factors
Associated symptoms

Loss of sensation
Part of the limb involved
Onset
Duration
Progression
Altered sensation
Tingling and numbness
Associated symptoms

Also ask h/o

Trauma
Malignancy
Diabetes mellitus
Leprosy
Procedures - injection etc
Diphtheria

Past history.
Diabetes mellitus,hypertension,leprosy,injection given in the recent Past Trauma.
Medical and surgical interventions.

Treatment history

Family history

Personal history
History of allergy to drug and food

Socio-economic history

Environmental history

Summary after history

General physical examination.

Patient is conscious, cooperative,
Oriented to Time place and person.
Built
Nourishment
Gait

Vitals:

Pulse
Blood pressure
Respiration
Temperature.

Pallor
Icterus
Cyanosis
Clubbing
Edema
Lymphadenolathy
Height
Weight
BMI
Head to toe examination.

Local examination.

Inspection.

Attitude and deformity

Wasting of muscles
Skin
Scar and wound

Palpation.

Local rise of temperature

Tenderness
Condition of Muscles
-Wasting
Flabby/not
-Skin
Look for loss of sensation
Hyperesthesia
-Scar

*Muscle power .(can be tested accordingly For suspected nerve lesions)

1.Accessory nerve
Trapezius muscle -Elevate shoulder against resistance
2.Hypoglossal nerve
Muscles of the tongue-Deviation
3.Long thoracic nerve
Serratus anterior-winging of scapula
4.Axillary nerve
Deltoid
5.Radial nerve
Brachioradialis
Extensor muscles of the wrist joint-look for wrist drop
Extensor digitorum
6.Median nerve
Flexor pollicislongus
Flexor digitorumsuperficialis and profundus: Ochsner's clasping test/pointing
index
Abductor pollicis:pen test
Oppenenspollicis

7.ulnar nerve
Flexor carpiiulnaris
Interossei:Card test
1st palmarinterossous and adductor pollicis :
Froment's sign

8.sciatic nerve.
Common peroneal nerve:Extensor muscles of the leg:look for foot
drop/Talipesequinovarus
Tibialnerve:Plantar flexors of ankle joint-Look for talipescalcaneo valgus

Sensation.
Tactile sensitivity
Pain
Temperature
Recognition of size, Shape and form of the object.
Position
Vibration

Reflexes.
Examination of whole course of suspected nerve

Movements: Active and passive.

Deformity.

Systemic examination.
Cardiovascular system
Central nervous system
Respiratory system
Abdomen

Summary

Provisional diagnosis

Investigation

Treatment
3.Malunion/Non-union of fracture

Patient particulars
Name
Age
Gender
Address
Education
Occupation
Date of admission.
Date of examination

Chief complaints:
Deformity of the limb

History of present illness.

Deformity of the limb
Swelling in the fracture area
Pain
Loss of function
Abnormal mobility at the fracture site
The amount and nature of violence.
H/o fracture
Involved limb/limbs
Single or multiple fracture sites

Treatment history in detail.

Past history.
Similar illness in the past
Any diagnosed joint diseases
Any other diagnosed systemic illnesses
Diabetes mellitus,tuberculosis,other illnesses like gonorrhea,syphilis,pneumonia
etc

Menstrual history (In females)

Marital and obstetric history (Females)

Family history.
Similar illness in the family .
Haemophilia,Tuberculosis,gout,rheumatism etc

Socioeconomic history

Environmental history.

General physical examination.

Patient is conscious, cooperative,
Oriented to Time place and person.
Built
Nourishment
Gait

Vitals:

Pulse
Blood pressure
Respiration
Temperature.

Pallor
Icterus
Cyanosis
Clubbing
Edema
Lymphadenopathy
Height
Weight
BMI

Head to toe examination.

Local examination.
Inspection.
Abnormal swelling and deformity
Attitude
Shortening
Overlying skin

Palpation.
Tenderness
Bony irregularity
Abnormal movement
Crepitus
Pain elicited by manipulation from a distance
Absence of transmitted movements.
Swelling
Wound

Measurement.
Longitudinal
Measurement of circumference of the limb
Movement

Complications.

Summary.

Provisional diagnosis

Differential diagnosis.

Investigation

Treatment.
4.Osteomyelitis(Bone disease)

Patient particulars

Name
Age
Gender
Address
Education
Occupation
Date of admission.
Date of examination

Chief complaints:

Pain
Restricted movement
Swelling

History of present illness.

Onset
Duration
Progression
Site involved
Extent
Sinuses
Associated symptoms
Trauma
Fever
Restricted movement
Treatment history.

Past history.
Similar complaints in the past
Trauma,tuberculosis.
Diabetes mellitus,hypertension.

Family history.
Tuberculosis,malignancy in the family.

Personal history.

Socio economic history.

Environmental history.

General physical examination.

Patient is conscious, cooperative,
Oriented to Time, place and person.
Built
Nourishment
Gait

Vitals:

Pulse
Blood pressure
Respiration
Temperature.

Pallor
Icterus
Cyanosis
Clubbing
Edema
Lymphadenolathy

Height
Weight
BMI

Head to toe examination.

Local examination.

Inspection.
Swelling
Skin over the swelling
Neighbouring joints
Muscular wasting
Shortening or Lengthening of bone.

Palpation.
Local rise of temperature
Tenderness
Swelling
Situation, size ,shape,surface,edge,consistency,
Bony irregularity.
Ulcer and sinuses.
Presence of fractures.
Neighbouring structures.

Percussion.
Localised tenderness( in case of chronic osteomyelitis ,Brodie's abscess)

Auscultation in case of pulsatile swelling.

Measurement.
Length of the long bone.

Examination of neighbouring joints.

Examination of lymph nodes

Summary
Provisional diagnosis
Differential diagnosis
Investigation
Treatment.