Principles

Identification data/ Personal identification

Chief complaints History

Observation
Examination Special tests Investigations Diagnosis

Identification data
Name
Age Gender

Occupation
Dominant side Address Etc..

Chief complaints
This is the patient's symptom(s) in their own words and should be no more than a single sentence.

History
While history taking the questions should start with open ended and then progress to closed ended type. H/O present illness H/O past illness Medical history Family history Personal history Social history

Observations
It starts as the patient enter the assessment area. Look for: Body alignment Any obvious deformity Bony contours Soft tissue contours Skin & nail color, texture etc. Symmetry Any scar Facial expression

Examination
Inspection (looking)
Palpation (Feeling) Percussion (tapping)

Auscultation (listening)

OR

Ortho Examination framework

Look
Feel Move

Active
Passive Measure Special tests functions

Palpation
Difference in the tissue tension and texture
Difference in the tissue thickness Abnormality

Tenderness
Temperature and its variation Pathological state of tissues Dryness or excessive moisture Abnormal sensations

Move
Active movements
Passive movements End feel

Capsular patterns
Resisted movements Isomteric Isotonic Joint play movements Joint crepitus, snapping and abnormal sounds.

Measure
ROM
MMT Limb length and girth

ADLS

Special tests
Special tests related to each joint.
Narrow your assessment according to the symptoms

and history.

Functional assessment
Through direct assessment and questionaires Barthels index Katz index SF36 FIM FMS etc..

Neural Examination
It includes the examination of complete nervous system starting from central to peripheral nervous system till receptors and effectors.

Neural Examination Framework

Inspection, mood and conscious level Speech and higher mental functions. Cranial nerves. Motor system. Reflexes Sensation. Co-ordination. Gait. Any extra tests. Other relevant examinations.

Investigations
Radiographic X-rays MRI CT Scans Ultrasound EMG NCV EEG ECG Echocardiography

 Lab investigations
Exercise testing/stress testing

Diagnosis