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.
Edited Sample Report
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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