This orthopedic assessment document contains sections on the patient's demographic details, chief complaints, medical history, vitals, physical examination findings, investigations, differential diagnosis, diagnosis, and treatment goals. The physical examination includes assessing the patient's posture, gait, range of motion, muscle strength, reflexes, and limb measurements. The diagnosis and problem list are provided based on integrating the history and examination findings. Short and long-term treatment goals are outlined.

1. ORTHO ASSESSMENT
DR.SAMIR JADAV

2. ASSESSMENT
NAME
AGE
GENDER
OCCUPATION
ADDRESS
HAND DOMINANCE
DATE OF ASSESSMENT
DEMOGRAPHIC DETAILS

3. CHIEF COMPLAINTS
HISTORY
H/O PRESENT ILLNESS
PAST MEDICAL HISTORY
FAMILY HISTORY
PERSONAL HISTORY
SOCIOECONOMIC HISTORY
FUNCTIONAL HISTORY

4. VITALS TEMP. - 98.6˚F/37˚C
RESPI.RATE- 16-20/min
HEARTRATE- 60-80 bpm
B.P. - 120-80 mmHg
ON OBSERVATION
BODY BUILT
POSTURE
ATTITUDE OF LIMB
ATTITUDE OF PATIENT
EXTERNAL APPLIANCES
DEFORMITIES
WOUND/SCAR
OEDEMA
SKIN/TROPHIC CHANGES
GAIT

5. ON PALPATION
WARMTH
TEXTURE OF SKIN
TENDERNESS
SPASM
OEDEMA
PULSE
CREPITUS
MUSCLE WASTING
PAIN ASSESSMENT
SIDE
SITE
DURATION

6. TYPE
NATURE OF PAIN
ONSET OF PAIN
RADIATING PAIN
A/F
R/F
INTENSITY OF PAIN: NPRS/VAS SCALE

7. ON EXAMINATION
MUSCLETONE
ROM :- AROM
PROM
ENDFEEL
JOINTPLAY
MMT
DTR - biceps,triceps,
brachioradialis, knee,
ankle jerk
LIMB MEASUREMENT :- LENGTH,
GIRTH
GAIT

8. INVESTIGATIONS
SPECIALTESTS
DIFFERENTIAL DIAGNOSIS
DIAGNOSIS
PROBLEM LIST

9. SHORTTERM GOALS
LONGTERM GOALS
MEANS