Orthopaedic examination-basic step- look, feel, move, measure

Orthopaedic examination-basic step- look, feel, move, measureCreated OnApril 17, 2020Last Updated OnOctober 28, 2020byadmin You are here: Main Clinical Examination Orthopaedic examination-basic step- look, feel, move, measure < All Topics Table of Contents Steps in orthopaedic examination   There are four basic steps in orthopaedic examination. They are, Look Feel Move Measure (some cases)   Look This is the very first step in physical examination. You must look the patient from front, side and back. If the patient can turn by himself, ask him to turn around otherwise you have to move around the patient. At the same time, you have to mention what you are looking for (running commentary is preferable). Do not forget to check the axilla by asking to lift the arm up, but bear in mind that this is not the “move” step. Do not touch the patient before you finish looking step, it will draw to the second step and you will miss some important information from the looking step. Generally, short case is around 10 minutes, so you should not spend more than 2-3 minutes to look and describe what you see and then move to the second step. Do not just stare at the patient with silent; your behaviour should be smart, active and professional. Silences make scary time, especially in exam situation so, try to explain the examiner in each and every step of your movement, what you are doing, why you have to do this etc. Examiners do not expect you to get the diagnosis just in looking step, so do not panic if do not get the diagnosis. Just keep going for clues for the diagnosis and explain clearly and loudly to the examiner what your finding is in looking step and say, “Now I would like to feel the patient”.   Feel   Before you start to feel, you may ask the patient if any painful area in his/her body, if present, you need to be reassured that you will be gentle and will not make the patient painful. In feeling, you need the knowledge of anatomy where will you feel for what structure (e.g. Femoral artery at mid inguinal point) and bony landmarks (e.g. Medial malleolus). You need to feel sequentially (e.g. from proximal to distal or distal to proximal, one limb after another) and systemically. Do not jump to and fro from one limb to another aimlessly. Do not massage purposelessly on patient limbs. For every patient, feel for temperature, sensation, pulses, tenderness, bony outline and landmarks. If you see any lump, ulcer or bony tenderness, you need to describe it in detail (I will discuss later in related session). Do not forget to compare with normal side until your examiner says you, “examine this limb only”. In some cases, examiner will focus on only one side because of the time constraints otherwise the principle of physical examination in orthopaedics is always compare both limbs. For feeling, you should not take more than one fourth of your total time allowance. In this step, we also expect running commentary and explain your examiner what you are feeling, where you are feeling e.g. bone or artery and finally what your finding is. After this step, you should get a diagnosis or at least differential diagnosis and later steps are to confirm your diagnosis. Even if you do not get the diagnosis at this stage, do not worry and just carry on, as far as your method of examination is correct, examiner will appreciate it. Sometimes the examiner will stop you after this step and discuss about your diagnosis, especially in the case like movement and measurement are not crucial to get the diagnosis. In that case, your clinical finding is very important to draw the conclusion since this is the last step of your physical examination. The accuracy of your finding is very important. You should able to interpret soft swelling as soft in consistency and hard swelling as hard in consistency. For which it is not enough to read the books, I would like to advise to practice on the patient several times to be able to differentiate different feelings such as soft, firm, hard, pulsatile etc. Notice the position of hand in feeling of dorsalis pedis pulse. Note: Bear in your mind that dorsalis pedis arterial pulsation is always proximal than where you think. If you feel between the first and second metatarsal, it is difficult to palpate. According to the principle of feeling of arterial pulsation, you should press against the bone. For the tenderness, in orthopaedics practice you need to differentiate soft tissue tenderness or bony tenderness. You may not get a case of fresh fracture in the exam, however, should know that sign of fracture is localized bony tenderness, not soft tissue tenderness. To elicit tenderness,...

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