. Orthopaedic Assessment. OrthopaedicsOne Clerkship. In: OrthopaedicsOne - The Orthopaedic Knowledge Network. Created Nov 25, 2010 18:46. Last modified Jan 05, 2011 11:34 ver.5. Retrieved 2019-02-16, from https://www.orthopaedicsone.com/x/E4DJAg.
- ID: age, sex, hand dominance + occupation (if relevant)
- CC: (chief complaint)
- HPI: (ChLORIDE FPP)
- (C) Character: sharp or dull pain
- (L) Location: region (joint) of origin
- (O) Onset: sudden vs. gradual
- (R) Radiation:
- (I) Intensity: how severe (scale 1-10), impact on ADLs (activities of daily living), is it getting better, worse or staying the same?
- (D) Duration: acute vs. chronic
- (E) Events associated: falls, morning stiffness, swelling, redness, joint clicking or locking, muscle cramps, muscle wasting, movement limitation, weakness, numbness or tingling, fever, chills, trauma (mechanism of injury), occupation activities, sports, repetitive movements
- (F) Frequency: intermittent vs. constant, have you ever had this pain before?
- (P) Palliative factors: is there anything that makes it better? (rest, activity, meds, heat, cold)
- (P) Provocative factors: is there anything that makes it worse? (rest, activity, etc.)
- PMHx: arthritis, gout, osteoporosis, connective tissue disease, past injuries, previous intervention in area of concern (surgery, injections, physiotherapy, etc.), other medical problems
- Meds: NSAIDs, acetaminophen, narcotics, steroids, immunosuppressants, ASA, anticoagulants, etc.
- Allergies: antibiotics, anti-inflammatories, anesthetics, etc.
- FHx: arthritis, osteoporosis, connective tissue disease, malignant hypothermia, etc.
- SHx: smoking, EtOH, occupation, activity level/exercise, use of mobility aids (cane, walker, wheelchair, etc.)
- O/E: VITALS, general appearance, ROS (cardiac, resp., neuro, etc.)
1.) Inspection: SEADS, gait, posture
- Erythema, Ecchymosis
2.) Palpation: TEST CA
3.) Range of Motion (ROM):
- Active ROM: joint proximal to the joint being examined is immobilized while the pt. moves the joint in question
- Passive ROM: examiner performs the maneuvers
4.) Neurovascular Assessment: distal pulses & capillary refill, skin colour/temp., sensation & muscle power
5.) Special Tests: joint specific
: always examine the joint above & below the area of concern (referred pain) and compare each step of the exam with the contralateral joint/side