Post on 17-Feb-2023
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
Guidelines for case writing in Orthopaedics
1.A detailed history has to be taken. When writing the chief complaints of the patient it has to be in a
chronological descending order.
2.Details of each of the chief complaints have to be documented.
3. The common clinical symptoms encountered in diseases of the musculoskeletal system, that of
pain, swelling, deformity, stiffness of joints, disability, paralysis, limp etc should be enquired.
At the end of the history a summary of the same should be presented and a list of differential
diagnosis has to be discussed. The diagnostic sieve of congenital, developmental, metabolic,
injuries, inflammatory, infection, tumors, degenerative, and miscellaneous should be used to narrow
down to the diagnosis.
4. Clinical examination details to be noted as under the subtitles of general examination, systemic and
local examination (musculoskeletal examination of the part). At the end of this, based on the history
and clinical examination, a list of possible differential diagnosis to be listed out and points in favor of
each diagnosis to be listed. Symptoms and signs have to be correlated with basic science in each
case.
5. With the list of differential diagnosis, list out the investigations required to arrive at a particular
diagnosis.
1. Write the investigations done by the hospital along with the reports. If you find additional
investigations done by the hospital, state if they were done for diagnostic or therapeutic
purposes. You do not need to detail on this.
7. Write the final diagnosis based on history, clinical examination and investigation.
8.Discussion on the diagnosis alone has to be written with a word on the etiology / mechanism of
injury, treatment modalities and their principles and the complications of the given condition.
9. Analyze the treatment as per literature.
10.No student will discuss any disparity whenever noticed with or in front of the patients or the
patient party. You may approach the faculty in the hospital or campus and discuss any such
doubts in person.
Important
1. Every case record will be written according to this protocol.
2. 3 case write-ups have to be presented for assignment work. Cases on Upper limb trauma,
Lower limb trauma, Spine and Cold Orthopaedics.
3. Case write-ups will be submitted before the end-of-posting examination in each semester.
The candidate will not be eligible for the EOP exams if not submitted in time.
4. The department will retain the project work; hence you are advised to keep the copy of the same for
your immediate reference.
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
Case 1
Name of the patient:
Age:
Sex:
Occupation:
Race:
Religion:
Nationality:
Place:
a. Chief complaints :(symptoms+duration+chronological order):
b. History of presenting illness:
(elaboration of the chief complaints – for the duration for the complaints):
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
c. Past history: (history prior to the duration of the chief complaints):
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
d. Previous treatment/ Drug intake/ Drug abuse/Drug allergy:
e. Family history:
f. Occupational history:
g. Menstrual history:
h. Personal and social history:
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
i. Systemic enquiry:
j: Summary of the history: (relevant salient features from the history which makes a
difference in understanding the case):
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
k. Provisional Diagnosis :with justification of the diagnosis
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
l. Differential Diagnosis / es:(with points in favor of each diagnosis) based on history
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
m. Physical examination
General examination(head to toe inspection of the patient):
Objectives:
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
3. Range of movements: to be documented in a tabular format in relevant joints examined
Joint RIGHT LEFT REMARKS (IF ANY)
& INTERPRETATION
ACTIVE PASSSIVE ACTIVE PASSIVE
Hip :Flexion 10-1000 10-120
0 0-120
0 0-120
0
100 flexion deformity
(R) side with
restricted flexion
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
4. Measurements:
Measurement Right Left DIFFERENCE
Apparent limb length
(incms)
True limb length
(incms)
Segmental lengths
Femur
Tibia
OR
Humerus
Ulna / Radius
INTERPRETATION OF FINDINGS
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
5. Specific tests:
n. Systemic examination: (Examination of relevant systems: draw diagrams wherever
necessary):
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
o. Summary:
p. Provisional diagnosis:(with points in favor of the diagnosis based on history and
examination findings):
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
q. Investigations with results (With normal values and interpretation of findings);
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
Radiology (with photos / Xerox of X-rays)
Type / Region /
Date
AP view
Lateral view
Other views
Radiological conclusion
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
r. Final Diagnosis: (based on history, examination findings and investigations):
s. Treatment:
t. Follow up:
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
DISCUSSION
(Emphasis on: Differential diagnosis, Investigations and results and Principles in management)
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
Case 2
Name of the patient:
Age:
Sex:
Occupation:
Race:
Religion:
Nationality:
Place:
c. Chief complaints :(symptoms+duration+chronological order):
d. History of presenting illness:
(elaboration of the chief complaints – for the duration for the complaints):
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
c. Past history: (history prior to the duration of the chief complaints):
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
d. Previous treatment/ Drug intake/ Drug abuse/Drug allergy:
e. Family history:
f. Occupational history:
g. Menstrual history:
h. Personal and social history:
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
i. Systemic enquiry:
j: Summary of the history: (relevant salient features from the history which makes a
difference in understanding the case):
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
k. Provisional Diagnosis :with justification of the diagnosis
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
l. Differential Diagnosis / es:(with points in favor of each diagnosis) based on history
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
m. Physical examination
General examination(head to toe inspection of the patient):
Objectives:
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
3. Range of movements: to be documented in a tabular format in relevant joints examined
Joint RIGHT LEFT REMARKS (IF ANY)
& INTERPRETATION
ACTIVE PASSSIVE ACTIVE PASSIVE
Hip :Flexion 10-1000 10-120
0 0-120
0 0-120
0
100 flexion deformity
(R) side with
restricted flexion
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
4. Measurements:
Measurement Right Left DIFFERENCE
Apparent limb length
(incms)
True limb length
(incms)
Segmental lengths
Femur
Tibia
OR
Humerus
Ulna / Radius
INTERPRETATION OF FINDINGS
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
5. Specific tests:
n. Systemic examination: (Examination of relevant systems: draw diagrams wherever
necessary):
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
o. Summary:
p. Provisional diagnosis:(with points in favor of the diagnosis based on history and
examination findings):
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
q. Investigations with results (With normal values and interpretation of findings);
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
Radiology (with photos / Xerox of X-rays)
Type / Region /
Date
AP view
Lateral view
Other views
Radiological conclusion
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
r. Final Diagnosis: (based on history, examination findings and investigations):
s. Treatment:
t. Follow up:
KULLIYYAH OF MEDICINE AND HEALTH SCIENCES
2016-2017
DISCUSSION
(Emphasis on: Differential diagnosis, Investigations and results and Principles in management)