ORTHOPAEDICS DEPARTMENT

Masha university

SECTION A HISTORY
1- Personal history ( BIO DATA of PATIENT)
Name
Sex/Age
Marital Status
Home Address
Date of Admission

2- CHIEF COMPLAINT
The problem(s) that made the patient come to clinic/hospital.
It is like a PREAMBLE/ABSTRACT to a scientific article.
Example:
“The patient (or name) came to the clinic/was brought to the A&E with 2
CHIEF COMPLAINT of pain ,swelling ,deformity ……etc due to injuries to the
thigh/arm/hand, sustained in a road traffic accident/at workplace/at home….etc., on the
same day/previous day..”

3- HISTORY OF present illness:

-Is it a new problem?

-Is it a complication arising out of an old problem (either treated or not treated)?

-If new: onset, duration… (as in History Taking specific to the complaint (Congenital,
Developmental, Degenerative, Traumatic, Neoplastic)

-Is the present complaint related to an old problem?

Is it an old fracture/injury which was treated and had complications?

Where treated? How long ago? What was the follow-up?
Went back to work/games/ADL?

4- Past Medical History

Medical problems requiring treatment,
Example: Diabetes, Hypertension, IHD, CVA, Asthma, etc.
Treatment: admissions, clinic, follow-up, medications, complications…
Current position/on treatment

5-Past Surgical History

Most relevant in relation to current orthopaedic problem.

Previous admissions/clinics/follow-up
 Previous surgery
Injury (fractures, etc.)
Gastro-intestinal cardiac ENT ………….etc Female: gynaecological, obstetric
4. Family History
Related illness (does not refer to accidents, more to inheritable illnesses)
Parents
Siblings

5-Social History:

Local or immigrant worker (health care support)

Marriage, status, children

Residence/house/apartment

Facilities and amenities: environment, stairs, toilets/wheel-chair friendly

Habits: smoking, hard liquor consumption (if relevant, not for paediatric patients)

ADL/sports/recreation

6-Drug and Allergy history:

Medical products (drugs)

Food and food products

Asthma

Skin problems

7- Review of symptoms at other Systems

Central nervous

Cardio-vascular

Pulmonary

Gastro-intestinal

Urologic

In women: Gynaecological

Examples of of symptoms

General: weight fatigue weakness fevers chills

Skin: rash itching dryness lumps nails

Eyes: vision pain redness tearing double vision glaucoma
cataracts

Ears: hearing tinnitus vertigo earache discharge

Nose: colds stuffiness hay fever nosebleed sinus anosmia

Mouth/Throat: teeth bleeding gums sore throat hoarseness dysphagia

Neck: lumps goiter pain stiffness

Respiratory: cough sputum (color/quantity) blood dypsnea wheezing asthma

8- Summary of history

9- Provisional & differential Diagnosis

Provisional Diagnosis based on History

With Reason

Section B: PHYSCIAL Examination

1- General examination:

A-General look: conscious, pale, irritable, attitude in bed-surroundings

- Vital signs (temperature, pulse, blood pressure, respiratory rate)

2- Local examination

-Look (Inspection – swellings, deformities, etc.)

-Feel (Palpation)

-Movements (active, passive)/Gai

-Special Tests (Limb length, girth, nerve tests, vascular tests, intra-articular
structures, reflexes, etc.)

3-General systemic examinations: examination: of other regions of body

Examine various body parts. In general your approach is to

1. Inspect: 2. Palpation: 3- Percussion.
4. Auscultation

Section c
1-investigation 2 -final or definitive diagnosis