ORTHO HISTORY TAKING

CASE SHEET PROFORMA

Hand
History

Demographics
o Age
o Occupation
o Handedness

Pain
o Location
point to where it is
o Radiation
does the pain go anywhere else
o Type
Burning, sharp, dull

o How long have you had the pain

o How did it start
Injury
Insidious
o Progression
Is it getting worse or is it remaining stable

o When
Mechanical
Rest
Nocte
o Aggrevating & Relieving Factors
start up, mechanical

Associated
o Stiffness
o Swelling
o Deformity / Contracture
Age of onset
Progression

o Click / clunk
o Givesway

o Numbness
o Weakness
o Paraesthesia

Red Flags

Risk Factors
o Duyputrens
Diathesis
Peyronies, Ledderhosen, Garrods
Family History, racial origin
Diabetes, Alcohol, Smoke, Epilepsy
Work
o RA
 Function
How has this affected your life
o Home
Precision
Pens
Buttons
Keys
Gross motor
Turning taps
Carrying shopping bags
Rising from chairs
Bedroom
Dressing
Bathroom
Washing
Hygiene
Feeding
Dupuytrens
Clumsy, catching in pocket

o Work
o Sport

Treatment
o Nonoperative
Medications
Analgesia
How much
How long
Physio
Orthotics
Walking sticks
Splints
o Operative

Past Medical History

o Family History
o

Any last questions

what would you like done?

Wrist
History & Examination summary

History
pain
o where,radiation,type
o how long, progression, when,nocte
o aggrevating,relieving
other
o stiffness
o instability
o click,clunk,catch
o numb, weakness, radiculopathy
function
o Home (ADLs)
 Bedroom
Dressing, back pocket, rise from chair
Bathroom
toilet,opposite underarm, comb
Kitchen
Eat
o Work
Lift, carry
o Sport
throw
past history
o neck,treatment,injury,surgery,similar,episodes
Exam Neck, Shoulder & Wrist

Exam
look:swelling,wasting,deformity,scars,ulnar styloid,red
feel:warmth,tenderness,bony landmarks
move:crepiations,active & passive ROM (dorsiflexion, palmarflaexion,radial & ulnar deviation,
supination & pronation)
spec:Watsons,Shuck,L/T ballot,midcarpal,piano key, TFCC load,Tinnel
power,neuro,vascular: (incl. grip strength)

Orthopaedic Elbow History-Taking

Introduction
o age
o occupation
o handedness
history of presenting complaint
pain
o location
global
localised
o radiation
towards hand
towards shoulder
towards neck
o type
o when, nocte, how long
o aggrevating, relieving
other
o stiffness
o clunk, lock
 o instability
o weakness, radiculopathy
function
o Home
Dressing
Coat
Bra
Bathroom
Toilet
Comb
Around the house
Shelf
Lifting & carrying
o Work
change of job
o Sport
Past History
o previous injury
what
mechanism
treatment
outcome
o previous surgery
o similar episodes

Shoulder & Upper Arm

History
Demographics

o Age
< 30
instability
very rare to have complete cuff tear
> 45
degenerative joint disease
RC tears
If cuff tear under 40 years old, then think
instability
manual labourer
throwing / overhead athlete
Adhesive capsulitis
o Occupation
o Handedness

Presenting Complaints
Pain

Where
o Rotator Cuff
anterolateral & superior
deltoid insertion
o Bicipital tendonitis
Referred to elbow
Radiation
Type
Severity
Onset
o when did it start
o how did it start
 acute
trauma
chronic
degenerative
Duration
Progression
o worse, better, same
Nocte, rest, constant
Aggravating / Relieving factors
o Position that symptoms
RC: Window cleaning position
Instability: when arm is overhead
o Neck pain
Is shoulder pain related to neck pain
If neck pain
Then ask about radiculopathy

o Causes
AC joint
Cervical Spine
Glenohumeral joint & rotator cuff
Front & outer aspect of joint
Radiates to middle of arm
Rotator cuff impingement
Positional : appears in the window cleaning position
Instability
Comes on suddenly when the arm is held high overhead
Referred pain
Mediastinal disorders, cardiac ischaemia

Associated
o Stiffness
o Instability / Gives way
Severe feeling of joint dislocating
Usually more subtle presenting with clicks/jerks
What position
Initial trauma
How often
Ligamentous laxity
o Clicking, Catching / grinding
If so, what position
o Weakness
Rotator cuff
especially if large tear
o Pins & needles, numbness

Loss of function
o Home
Dressing
Coat
Bra
Grooming
Toilet
Brushing hair
Lift objects

Difficulty working with arm above shoulder height

Top shelves
Hanging washing
 o Work
o Sport
Previous Treatment
o Nonoperative
medications
injections
physiotherapy
o Operative
Past Medical History
o Previous trauma
o Previous surgery
Family History
o Ligamenous laxity
o MDI

Spine

Demographics
o Age
o Occupation

pain
o location
point to where the pain is
leg versus back
o radiation
exact location
L4
L5
S1
o Type
Burning, sharp, dull

how long
how did it start
o injury or insidious
progression
better, worse, same

when
o Mechanical
o Rest, night pain
o Constant
Aggrevating,relieving
o Hills
Neuropathic
extension & walking downhill
walking uphill & sitting
vascular
walking uphill
generates more work
rest
standing is better than sitting due to pressure gradient
o stairs
o shopping trolleys
o coughing, straining
o sitting
o forward flexion
 Associated
o Paresthesia
o Numbness
o Weakness
L4
L5
S1
o Bowel, Bladder
o Stiffness
o Deformity
o Cervical myelopathy
Clumbsiness of hand
Unsteadiness
Manual dexterity

Red Flags
o Loss of weight
o Constitutional symptoms
o Fevers, sweats
o Night pain, rest pain
o History of trauma
o immunosuppresion

Functional
o Home
Walking distance
Shoes, socks
Stairs
Hills
o Work
Manual vs office
Lifting, vibration, sitting
o Sport

Treatment
o Nonoperative
Medications
Analgesia
How much
How long
Physio
Orthotics
Walking sticks
Braces
o Operative

Past Medical History with emphasis on Risk Factors

o Family history
o Risk factors
Smoker
o Shx
occupational
o Prognostic factors
o Management issues

Hip

pain
o where
 o radiation
o when
o type
o nocte, at rest
o aggrevating,relieving
o how long
o start up, mechanical
other
o limp
o stiffness
o deformity
o giveway
o snapping & clicking
function
o walking distance
o stairs
o socks
o get & out of cars
o how has this affected your life
o Home
o Sport
o Work
treatment
o Nonoperative
Physio
Orthotics
Medications
Walking sticks
o injury
o surgery
o what would you like done?

Knee
History

Age
Occupation

Pain
o Location
point to where it is
o radiation
does the pain go anywhere else
o Type
Burning, sharp, dull

o How long have you had the pain

o How did it start
Injury
Mechanism of injury
Position of leg at time of injury
Direct / indirect
Audible POP
Could you play on or did you leave the field?
ACL
Did it swell at the time
Immediately
Haemathrosis
 Delayed
Traumatic synovitis
Audible POP
How was it treated?
Insidious
o Progression
Is it getting worse or is it remaining stable
Is it better, worse or the same

o When
Mechanical / Walking
Rest
Nocte
constant
o Aggravating & Relieving Factors
stairs
start up, mechanical
pain with twisting & turning
up & down hills
kneeling
squatting

Other
o Swelling
Length of time
Progression
? painful
Local vs generalised
Associated with injury
o Locking / clicking
Loose body, meniscal tear
Locking vs pseudo-locking
o Giving way
Buckling 2 pain
ACL
Twisting
PCL with PLC
Going downstairs
Patella
MCL
Cutting movements
Red Flags

Risk Factors

Function
o How has this affected your life
o Home
getting out of chairs / bed
socks
stairs
squat or kneel for gardening
walking distance
get & out of cars
o Work
o Sport
Type & intensity
Run, jump
 Treatment
o Nonoperative
Medications
Analgesia
How much
How long
Physio
Orthotics
Walking sticks
Splints
o Operative

Past Medical History

o Family history

Any last questions

what would you like done?

What problem would you like fixed?

Foot & Ankle History

Demographics
o Age
o Occupation
o Diabetes, Rheumatoid Arthritis, Smoker

pain
o where
o radiation
o type

o How long
o how did it start
o progression
getting better, worse or the same

o when
nocte,rest. Mechanical, constant
o aggravating,relieving

associated
o instability,giveway
o stiffness
o clicking, grinding
o swell,deformity,cosmesis
o numbness,tingling

function
o home
walking distance
shoes & socks
sticks
limp
o work
o sport
 Treatment
o Nonoperative
Medications
Analgesia
How much
How long
Physio
Orthotics
Walking sticks
Splints
o Operative
When, what results, complications

Exam (Standing)
look: shoes,sticks,calipers,front,side,back,single toe rise,Coleman
feel: spine
move: gait,toe walk,heel walk
Exam (Supine)
look:sole of foot (wear pattern),plantar keratoses

dorsal corns (soft & hard), swelling, deformity, redness, scars

feel: pulses, sole of foot, MT heads,MTP joints,interMT spaces,toe

tug,"Lachman",plantar fascia, rest of foot/ankle:systematic

move:ankle,subtalar,midtarsal,MTP, IPJ
ligs:ankle-AP drawer etc
power,neuro: (tib post, tib ant,peroneals etc.)