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I N T R O D U C T I O N

• Pain medicine

relieving pain

• Diagnosis based

care

H I S T O R Y

TA K I N G

• Adequate time

• Listen carefully

• Empathetic

• Trust building

• Do not intervere

• Pschosocioeconomic & spiritual

codition

• - quantity: VAS

- quality: nociceptive

- mode of onset and location

- duration & chronicity

- provocating & relieving factors

- special character

- timing of pain

- relation with posture

- associated complaints

CONT..

Rule out red flags or warning signs: inf, trauma, tumor

Past history: DM, inflamatory disorder, op, trauma

Psychosocial assessment history: occupation, vocation, sos

economic status, depression, sleep habit

Family history: RA, FM

Treatment history

GENERAL EXAMINATION

Sign of distress: wincing, sweating, protecting

Facial appearance: anxious, depressed, moon face

Gait and posture: antalgic, trendelenburg, waddling, stooped

Mental status: orientation, calculation, memory, speech,

comprehension

Built, nutrition

State of clothing

Gait Features Disease

Antalgic gait Limited range of motion

with inability to bear full

weight on affected

extremity results in limp

with slow and short steps

Degenerative arthritis,

injury,fracture, septic

arthritis.

Cerebellar gait Staggering wide based

gait, positive Romberg’s

sign

Cerebellar CVA, Vitamin

B12 deficiency

Frontal gait (gait apraxia) Hesitation on starting to

walk on turning

Dementia, non-pressure

hydrocephalus

Hemiparetic gait Weak and spastic limb

extended and

circumducted

CVA with hemiparesis

Paraparetic gait Stiff scissor like walk with

leg adduction and

extension. Associated with

bilateral weakness.

Spinal cord lesions,

bilateral cerebral lesion.

Gait Features Disease

Parkinsonism gait Shuffling gait with short

steps

Parkinsonism

Pelvic Rotational Wink Pelvic rotates >40 deegres

in axial plane towards the

affected hip. Maladaptive

gait allows for terminal hip

extension on walking.

Intra-articular hip

disorders.

Ataxic gait Unsteady gait, worse with

vision impairment or at night

Diabetic neuropathy,

Vitamin B12 deficiency

Stepping gait Hyper flexed hips and knees

on ambulation which

compensates for foot drop.

Distal motor neuropathy.

Trendelenburg gait Pelvis tilts to the normal side

while upper trunk tilt to the

affected side.

Abductor wakness

(gluteus medius) or

intrinsic hip pathology

Wadding gait Swaying, symmetric, wide

based gait with toe walking

Osteitis pubis, pregnancy,

muscular dystrophy

GENERAL EXAM CONT.

Vital signs incl pain

BH, BW, BMI (Normal 18-25)

Complete exam from head to toe if needed

Tender points

Extremities:

o Oedema:

o Swelling: heberdens node (DIP OA), Bouchard node (PIP

OA), Rheumatoid nodule

o Deformities: Swan neck, Buttonier def, ulnar dev, Dupuytren

contracture, trophic changes (ulcer, burn), genu valgus/varus

Active

Movement

Passive

Movement

Active

resistive

Movement

StretchSite of

tenderness

Muscle + - excl tear + + +

Bursae + + + + +

Capsule + + - + +

Joint + +ROM & path.condition + USG

to confirm

+

Ligament + + +

Nerve Nerve injury sign:

Bone Inflammation sign , # sign

pain

structure

SUPPORTING EXAMINATION

- USG

- Plain Radiograph

- MRI

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

TREATMENT