#ComprehensiveClinicalCases

#Orthopedics: 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, joint stiffness, 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.