Judgments Musculoskeletal Module

Orthopedic sheet
A-history taking
1-personal history

• Name
• Age
• Sex
• Address
• Telephone number
• Occupation
• Marital status
• Special habits
• Handedness=== only in upper limb injury

2-present history

Mechanism of trauma:
Type of trauma:
Date of admission:
Date of reduction:
Date of fixation:
Type of operation:
Date of operation:
Date of first physical therapy session:

3-past history

Any past problems related to present injury

4-medical history

Any health problems related or not related to present injury

5-family history




Chief complaint
= only one problem

, = by the patient`s own words
= no medical terms
= the most worse for the patient

Diagnosis

>right/left/bilateral
>injured bone or joint
>site of injury in the bone
>type of injury
N B.>method of fixation even if temporary
>complication if the injury is complicated



Physical assignment
A-inspection

1-general

-face expression
-mentality
-body posture (normal-misalignment)
-body built
-gait (normal-abnormal)
• Detect the type of deviation during each separate assessment
2-local

-skin color
-swelling (increased size)
-atrophy (decreased size)
-apparent spasm
-leg length discrepancy
-abnormal position
-assistive devices
-deformity
-scares
-wounds
B-Palpation & testing

1-Pain assessment