Home » Joints » Hip » History & Physical Form History & Physical Form September 23, 2020September 14, 2020 by Data Trace Editor History & Physical Form (best viewed w/ Netscape) Please fill out the following information and press the SUBMIT button: Please enter your e-mail address: CRW CRWms AB TPV History ROS and Non Ortho PE Orthopaedic PE Spine Vascular Hip Knee Ankle Write in today's date: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / / 97 Attending: Vail McCollum Scully Nunley (other: ) Dictator: Vail C.R. Wheeless McCollum Scully Nunley (other ) ---------------------------- - History: Patient name: Hospital number: Age: Date of Birth: / / Gender: male female Race? white African american hispanic asian (other: ) Describe the nature of the current symptoms / problem: Has function at work been impaired by this orthopaedic problem? yes no other Off work due to a present orthopaedic problem? yes no other Current employement situation: homemaker student currently working leave of absence unemployed disabled or retired because of health retired (not due to health) (other: ) How much physical labor is currently performed? none (sedentary) occassional / light work moderate physical work heavy labor (other: ) Previous Surgical Treatment: Past Medical History: (date) Medications: Previous Treatment Methods? Non-steroidals: never used stopped due to GI upset stopped due to GI ulcer tried - not effective moderately effective highly effective (other: ) Oral steroids: pills - not effective pills - moderately effective pills highly effective Steroid Injection: never tried injection not effective injection - moderately effective injection - highly effective If effective, how many weeks of relief: 1 week 2 weeks 3 weeks 1 month 2 months 3 months 4 months 5 months How many injections over the past year: 1 injection 2 injections 3 injections 4 injections 5 injections 6 injections Physical Therapy: never tried not effective moderately effective highly effective What are the patient's goals or expectations for improvement? History ROS and Non Ortho PE Orthopaedic PE Spine Vascular Hip Knee Ankle Orthopaedic Physical Exam: Weight? lbs - Assessment of Gait: normal antalgic gait pattern antalgic gait pattern - Leg Lengths: Are they equal? yes no describe if unequal: - Spine: - see" spine menu: - reflexes: left knee: 1+ and symmetric 2+ and symmetric 3+ and symmetric 4+ and symmetric right knee: 1+ and symmetric 2+ and symmetric 3+ and symmetric 4+ and symmetric left ankle: 1+ and symmetric 2+ and symmetric 3+ and symmetric 4+ and symmetric right ankle: 1+ and symmetric 2+ and symmetric 3+ and symmetric 4+ and symmetric - Motor Exam: Psoas left: 0/5 1/5 2/5 3/5 4/5 5/5 right: 0/5 1/5 2/5 3/5 4/5 5/5 Quadriceps left: 0/5 1/5 2/5 3/5 4/5 5/5 right: 0/5 1/5 2/5 3/5 4/5 5/5 Tibialis Ant left: 0/5 1/5 2/5 3/5 4/5 5/5 right: 0/5 1/5 2/5 3/5 4/5 5/5 Ext. Hallucis left: 0/5 1/5 2/5 3/5 4/5 5/5 right: 0/5 1/5 2/5 3/5 4/5 5/5 Gastrocnemius left: 0/5 1/5 2/5 3/5 4/5 5/5 right: 0/5 1/5 2/5 3/5 4/5 5/5 - Sensation: (other: ) Normal Stocking glove - Vascular Exam: normal exam both DP and PT dopplerable but not palpable. (other: ) History ROS and Non Ortho PE Orthopaedic PE Spine Vascular Hip Knee Ankle - Hip Joint: How far can the patient walk? wheel chair dependent minimal - sometimes needs a wheel chair short distances - can't shop 1 block - can shop 2 blocks - can shop 3 blocks - can shop can walk long distances Have ambulatory assistive devices been used? never tried not effective moderately effective highly effective Can the patient put on shoes and socks? can't put on socks can but is difficult not a problem - Flexion.... - Left 10 deg 20 deg 30 deg 40 deg 50 deg 60 deg 70 deg 80 deg 90 deg 100 deg 110 deg 120 deg 130 deg - Right: 10 deg 20 deg 30 deg 40 deg 50 deg 60 deg 70 deg 80 deg 90 deg 100 deg 110 deg 120 deg 130 deg - Extension - Left - 10 deg - 20 deg - 30 deg 0 deg 10 deg 15 deg 20 deg 30 deg 40 deg - Right: - 10 deg - 20 deg - 30 deg 0 deg 10 deg 15 deg 20 deg 30 deg 40 deg - Abduction - Left 0 deg 10 deg 15 deg 20 deg 30 deg 40 deg 50 deg 60 deg 70 deg 80 deg 90 deg - Right: 0 deg 10 deg 15 deg 20 deg 30 deg 40 deg 50 deg 60 deg 70 deg 80 deg 90 deg - Trochanteric tenderness: no trochanteric tenderness trochanteric tenderness severe trochanteric tenderness - Push pull test (for loosening of THR components) - Comments: - Radiographs: - PreOp Total Hip Radiographs: - Post Op Evaluation of THR: - acetabular component: normal acetabular component - polyethylene wear: no evidence of wear - femoral component normal uncemented femoral component normal cemented femoral component - comments: - Knee Joint: - see: knee joint: - Effusion: no knee effusion small knee effusion moderate knee effusion large knee effusion - Joint Line Tenderness: medial joint line tenderness medial joint line tenderness lateral joint line tenderness para-patellar tenderness - Flexion.... - Left 10 deg 20 deg 30 deg 40 deg 50 deg 60 deg 70 deg 80 deg 90 deg 100 deg 110 deg 120 deg 130 deg - Right: 10 deg 20 deg 30 deg 40 deg 50 deg 60 deg 70 deg 80 deg 90 deg 100 deg 110 deg 120 deg 130 deg - Extension - Left 0 deg 10 deg 15 deg 20 deg 30 deg 40 deg 50 deg 60 deg 70 deg 80 deg 90 deg - Right: 0 deg 10 deg 15 deg 20 deg 30 deg 40 deg 50 deg 60 deg 70 deg 80 deg 90 deg - specific tests: Lachman: negative less than 2 mm upto 5 mm upto 5 mm upto 1 cm Pivot Shift: negative pivot gluide positive - Comments: - Ankle Joint: - Plantar Flexion.... - Left 0 deg 10 deg 20 deg 30 deg 40 deg 50 deg 60 deg 70 deg - Right: 0 deg 10 deg 20 deg 30 deg 40 deg 50 deg 60 deg 70 deg - Dorsiflexion......... - Left 0 deg 5 deg 10 deg 15 deg 20 deg 25 deg 30 deg - Right: 0 deg 5 deg 10 deg 15 deg 20 deg 25 deg 30 deg - Comments: ------------------------------------------ History ROS and Non Ortho PE Orthopaedic PE Spine Vascular Hip Knee Ankle Non Orthopaedic Review of Systems: Head........ Normal Abnormal () Mouth...... Normal Abnormal () CV............. Normal Abnormal () Pulm........ Normal Abnormal () GI.............. Normal Abnormal () GU-Fem.. Normal Abnormal () GU-Male: Normal Abnormal () - Non Orthopaedic Physical Exam: Head and Neck: Normal Abnormal (see below) cushingoid torticollis lymphadenopathy cachexia rashes (other: ) Eyes: Normal Abnormal (see below) exophthalmos ptosis Horner's syndrome strabismus Teeth: Normal Abnormal (see below) gingivitis multiple dental caries Cranial Nerves: Normal Abnormal (see below) palsy of CN II (visual) palsy of CN III (medial rectus) palsy of CN IV (trigeminal) palsy of CN V (fascial musculature) palsy of CN VI (lateral rectus) palsy of CN VII (fascial musculature) palsy of CN VIII (acoustic) palsy of CN IX (glossopharyngeal) palsy of CN X (vagus) palsy of CN XI (spinal accessory) palsy of CN XII (hypo-glossal) (comments: ) Chest Normal Abnormal (see below) wheezes rhonchi rhonchi rales pectus carinatum pectus excavatum (other: ) Heart Normal Abnormal (see below) systolic murmur diastolic murmur irregular rate murmur (other: ) Breast Exam: Abdomen: Normal Abnormal Rectal / Prostate: Skin: Normal Abnormal (see below) herpetic zoster skin lesions contact dermatitis allergic eczematous dermatitis psoriatic lesions impetigo sebaceous cyst urticaria cyst pigmented nevi cafe au lait patches seborrheic keratosis furuncle tinea pedis tinea corporis - involving which part of the body? Nails: Normal Abnormal (see below) onycholysis clubbing paronychia anonychia psoriatic nail deformity tinea unguium ingrown nail subungual hematoma koilonychia - involving which part of the body? Address: address city......... state...... zip.......... Original Text by Clifford R. Wheeless, III, MD.