For Ward Presentation — Department of Orthopaedics
| Date:
1. Identification & Presenter Details
Patient Name
Age / Sex
IPD / Bed No.
Occupation
Address
Date of Admission
Presenting Student & Roll No.
History given by
2. Chief Complaints
Tick all that apply (patients often present with more than one). Fill site, side and duration for each selected.
✓
Chief Complaint
Side
Site
Duration (since)
Pain
Swelling
Deformity
Inability to bear weight / use limb
Restriction of movement / stiffness
Instability / giving way
Weakness
Numbness / tingling
Wound / discharge
Limp (paediatric)
Other:
3. History of Present Illness
Mode of onset / Mechanism of injury
Date, time & place of injury
High / low velocity trauma
Character of Pain — SOCRATES
To be filled whenever Pain is a chief complaint.
S — Site
O — Onset
C — Character
R — Radiation
A — Associated symptoms
T — Timing
E — Exacerbating / relieving factors
S — Severity (0–10)
Associated symptoms
4. Past, Personal, Family & Treatment History
Past History
Family History
Personal History
Treatment / Drug History
5. General Physical Examination
Build
Nutrition
Consciousness
Sign
Absent
Present
Details (site / grade)
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema
Vitals
PR (/min)
BP (mmHg)
RR (/min)
Temp
SpO2 (%)
RBS
GCS
6. Local Examination — Region:
A. Inspection (Look)
B. Palpation (Feel)
C. Movement (Move) — Active & Passive Range of Motion
Note: at minimum, one joint above and one joint below the affected joint must be examined — e.g. examination of the hip joint is incomplete without examination of the knee joint.
Joint / Movement
Active ROM (affected)
Passive ROM (affected)
Normal side (for comparison)
D. Measurements
Parameter
Affected side
Normal side
Difference
True length
Apparent length
Circumference (at level: )
E. Special Tests
F. Examination of Swelling / Lump (if applicable)
To be filled whenever Swelling is a chief complaint.
Inspection
Site & Size
Shape & Surface
Skin Changes
Special Movements
Palpation
Temperature & Tenderness
Edges & Margins
Consistency
Mobility
Special Tests
Fluctuation
Transillumination
Reducibility / Cough Impulse
Regional Lymph Nodes
7. Examination of Spine / Adjacent Joints (if indicated)
8. Systemic Examination
System
Normal
Abnormal
Details
Cardiovascular System
Respiratory System
Per Abdomen
Central Nervous System
9. Investigations
✓
Investigation
Findings
X-ray
CT scan
MRI
Hb / TLC / platelet count
Blood grouping & typing
RBS
Coagulation profile
Renal function test
Other:
10. Diagnosis
Provisional Diagnosis
Differential Diagnosis
11. Treatment Plan
12. Summary
Auto-generated from ticks & entries above, in the fixed order of the sections — edit freely before presenting.
Presenting Student's Signature
Countersigned by Faculty / Resident
Orthopaedic Clinical Case Proforma — for teaching purpose · not a legal medical record