This report is a sample of a very basic clinical evaluation of a patient seen by a physician specializing in orthopedic surgery. This sample medical report may also include a style, abbreviations, or report format that are unusual, and if so, this would be due to the preference of the dictating physician.

 

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Mrs. **** F/38yrs

C/O pain both knees-1yr non-radicular pain.

No H/O clicking/locking.
No H/O instability.
No H/O other major joint involvement.
No H/O swelling.
H/O trivial trauma 1 year ago: missed step on staircase.
No H/O fever.
No H/O TB contact.
No H/O other medical problems.
H/O occasional pain on climbing stairs.

L/E of knees: - Right      Left
Swelling: Absent      Absent
Effusion: Absent       Absent
Tenderness: Medial femoral condyle      Medial femoral condyle
Flexion deformity: Absent      Absent
Joint line tenderness: Absent      Absent
Patellar tenderness: Mild      Mild
Varus/valgus: Absent      Absent
Range of movement: 0° -130°      0° -130°
Medial ligament laxity: Absent      Absent
Lateral ligament laxity: Absent      Absent
Cruciates: Intact      Intact
McMurray's test: Negative      Negative
"Q" angle:       Quadriceps wasting: Absent      Absent
Power: Grade 5      Grade 5
Patellar crepitus: Present      Present
Retro patellar tenderness: Present      Present
Distal pulsations well felt
Hips normal

Clinical diagnosis: Patello-femoral arthritis.

Investigations: - CBC; ESR; RA Test; S; Uric acid; X-rays, both knees, standing, Skyline view

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