Orthopedics History

History Taking in Orthopedics

History taking

• Patient’s story
• Doctor/student reconstructs the history
  • Open ended questions
    • How do you feel now
  • Leading questions
    • What increases the pain?
    • Can you open a door key?
    • Can you comb your hair?

Orthopedics History

• History Structure:

  • Patient Demographic
  • Chief Complaint
  • History of Presenting Complaint
  • Past medical/surgical history
  • Medication history
  • Family history
  • Personal history and background
  • Diet
  • Activity
  • Systemic review

• Patient Demographic

  • Name
  • Age
  • Occupation
  • Hand Dominant

• Chief Complaint:

  • Site
  • Onset
  • Progression
  • Management

• History of Presenting Complaint

  • Pain
  • Swelling
  • Deformity
  • Limping
  • Stiffness
    • Usually related to function
  • Loss (altered) function
    • Caused by: stiffness / pain / deformity / instability / weakness
  • Altered sensation

• Pain

  • Site
  • Onset
  • Character
  • Radiation
  • Associations
  • Time course
  • Exacerbating/relieving factors
  • Severity

SOCRATES

• Site:

  • Referred Pain perceived at a location other than the site of the painful stimulus. this pain referred along the tissues developed from the same sclerotome -somite. e.g. Discogenic pain with no thecal or root compression radiated from L-S spine to groin, gluteal region, but not down to the knee. Hip: to the medial aspect of the thigh and knee
  • Radiating pain: pain begins in one place and travels to another location along the path of a nerve. e.g. Sciatica :root pain radiated to lower limb below the knee

• Onset:

  • When did it start?

• Was it

  • Gradual or sudden? (acute – related to incident/action)
  • Constant or intermittent?

• Character:

  • What is the pain like e.g.
    • Sharp,
    • Burning
    • Tight?

• Radiation:

  • Pain perceived at the site of stimulus and radiate to another site
  • Does it radiate/move anywhere?

• Associations:

  • Is there anything else associated with the pain e.g.
    • Swelling
    • Sweating
    • Fever
    • Vomiting

• Time course:

  • Does it follow any time pattern, how long did it last?

• Exacerbating/relieving factors:

  • Does anything make it better or worse?

• Severity:

  • How severe is the pain
  • Consider using the 1-10 scale

SOCRATES

• Stiffness

  • Patients complain of loss of/altered function, not stiffness
    • Can not comb hair, can not bend forward, can not sit cross-legged, can not sit in prayer, …
  • Joint involved
  • Cause:
    • Real stiffness of joint / mechanical block
    • Protective mechanism:
      • Muscle spasm to avoid pain on movement of joint
  • Generalized: systemic disease
    • e.g. Rheumatoid Arthritis, Ankylosing spondylitis
  • Localized
    • To a particular joint

• Swelling

  • Soft tissue, joint, bone
  • After trauma:
    • Injury or reactive
  • Rapid or Slow developing
    • Rapid: bleeding / Slow: effusion
  • Painful vs. Painless
  • Constant vs. comes and goes
  • Size:
    • Same, increasing, decreasing

• Deformity

  • Progressive, or improving?
  • Impairing function?
  • Associated with
    • Pain
    • Stiffness
    • Other metabolic diseases

• Functional affection:

  • Relate to normal function of part
    • Walking
    • Bending, Praying
    • Going to toilet
    • Sitting cross-legged
    • Eating
    • Reaching,
    • Holding,
    • Opening,
    • etc…

• Instability

  • Joint “gives way” or “jumps out of place”

• Weakness

  • Generalized: part of a systemic disease
  • Localized: Patients usually describe it as:
    • The limb is “dead” / “heavy”

• Associated conditions / other diseases

• Careful about history of mild trauma

  • History of mild trauma, especially in children, can be a normal daily occurrence

• Past medical/surgical history

• Medication & Allergy history

• Family history

  • Genetic - e.g. RA, CDH
  • Communicable - e.g. TB

• Personal history and background

  • Occupation
  • Travel
  • Recreation
  • Home condition
  • Drug or Alcohol abuse

• Diet

  • Food / drinks (good and bad!)
  • Sun exposure

• Activity

• Systemic review

  • Respiratory – e.g. TB
  • UTI – source of infection
  • GIT – deficiency
  • Renal – disease

Summary - History-taking

• Chief complaint
  • Onset, Progression, Management
    • Pain
    • Swelling
    • Deformity
    • Limping
    • Stiffness
    • Loss (altered) function
    • Altered sensation
  • Detailed mechanism of injury in trauma
    • High velocity Vs. Low velocity
    • Open Vs. Closed
• Relate to function