Orthopedic Case Taking Outline

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I- History

1- Personal Data

  • Name & Age
  • Sex & habit
  • Occupation
  • Address

 

2- Presentation

  • Complaint
  • Onset
  • Duration
  • Course

 

3- Present History

  • Trauma
  • Pain details
  • Function
  • Diseases

 

4- Past & Family

  • Illness
  • Treatment
  • Accidents
  • Family History

 


II- General Examination

1- Vital Signs

  • Pulse
  • Temp.
  • B. P.
  • Respiration

 

2- General Appearance

  • Facial express.
  • Posure
  • Body develop.
  • Physiolog. age

 

3- System Exam

  • Heart
  • Chest
  • Abdomen
  • Pelvic Organs

 

4- Systematic exam

  • Head
  • Face
  • Trunk
  • Limbs

III- Local Examination

1- Inspection

  • Skin
  • Muscles(A.S.)
  • Swelling(G.L.)
  • Deformities

 

2- Palpation

  • Temperature
  • Tenderness
  • Confirm inspection
  • Landmarks (B., S.)

 

3- Movement (A, P.)

  • Pain
  • Range
  • Crepitus
  • Abnormal       

 

4- Other Examination

  • Measurement
  • Other Regions
  • Special Tests
  • Attitude & Gait

IV- Investigation

1- Imaging

  • X-Ray, Sinogram
  • U. S., electrodiag.
  • C. T. Scan
  • M. R. I. (contrast.)

 

2- Laboratory

  • Blood composition
  • Urine composition
  • C/S (pus, discharge)
  • Aspirate(fluids)

 

3- Isotopic Scans

  • Tichnitium
  • Gallium
  • Indium.

 

4- Histopathology

  • Bone
  • Cartilage
  • Soft Tissue
  • Neoplasm

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