The
history
Learning objectives
1.
To understand the three key types of history, their function and the
different way in which they are obtained.
2.
To understand the three zones of abnormality that a history should
address.
Introduction
The importance of
taking a history in musculoskeletal disorders is threefold (Table
20.1).
.Its first function is to allow the patient to list the problems that
they are experiencing and to define what it is that they are hoping to gain from
this consultation. This part of the history
should be used to ‘set the agenda’ for the consultation.-
.
• The final phase is only needed if surgery is a possible option.
The questions here are directed at determining the patient’s ‘fitness for
surgery’.
Setting
the agenda
In this phase the patient should be encouraged with open questions to do
most of the talking. As they talk it should be possible to divide the
patient’s problems into three main areas: pain, dysfunction and deformity (Table
20.2).
Pain
Patients should be asked to define in what way the pain troubles them,
as the answer may give the clue to how this can best be managed if it cannot be
cured. For example, if it is pain at night stopping sleep, then a combination of
pain killers and sleeping tablets might offer the best solution if no other is
available. If, however, the pain occurs in a joint on weight-bearing a splint
might stabilise the joint and make the pain manageable.
Dysfunction
A patient may complain of loss of function as a result of pain,
stiffness, weakness, instability or even locking. In the first instance the
patient should be allowed to describe in their own words what it is they can no
longer do. This may be something like inability to reach up to hang clothes on
the washing line. This problem will later be translated into a clinical
diagnosis, but at this stage should be reported in the patient’s own words.
Deformity
This may be much more of a concern to the patient than might seem
reasonable to you. Patients may want bunions corrected not because they are
painful (although they may initially claim this), but because they are
unsightly. It is crucial to be clear about the patient’s real reasons for
seeking treatment, and what it is they hope you will be able to do about it
before embarking on the next stage of the interview.
This part of the interview should be summarised and recorded as the
patient’s problems and expectations.
History
for diagnosis
The ‘history for diagnosis’ leads directly on from taking a
‘history for agenda’ but the structure of the interview changes. Instead of
open questions aimed at getting the patient to talk about how they see their
problems, each question is now carefully designed to confirm or exclude a
differential diagnosis derived from the initial part of the interview. The
same categories are used as before — pain, dysfunction and deformity — but
this time the characteristics of each are explored in detail, searching for
clues to causation, association and alleviating factors. The main areas to be
covered are as follows.
Onset
A careful history of how the problem was first noticed is diagnostically
useful. In sports medicine it is usual to divide onset into three categories:
acute extrinsic, acute intrinsic and chronic (Table
20.3).
Acute
extrinsic. This is associated with external trauma. A limb which is deformed,
after being hit with a stick, is likely to be broken. If it is painful but not deformed then it is likely to be
bruised.
Acute
intrinsic. This occurs when the human body is under load and fails. In young
people this may be a ligament (e.g. anterior cruciate ligament in a footballer,
who twists at speed on a fixed foot). In older people it might be a broken bone
(e.g. a fractured neck of femur in an elderly osteoporotic patient who tripped).
Chronic.
These problems are those where the onset is not clearly associated with any
traumatic event, but just gradually appears. An example is osteoarthritis of the
shoulder.
Association
The human brain is programmed to seek patterns, and may do so even when
there is no pattern to see. Just because a patient feels that there is an
association between an event and onset of an illness does not mean that this is
correct. Conversely, you may need to seek associations which had not occurred to
the patient.
Development
The natural history of the problem may also give clues to diagnosis
causation and even treatment. If the condition spontaneously resolves, then
returns, the cause for recurrence needs to be sought. For example, being
compelled to sit for a long period in one place may exacerbate pain from a
prolapsed intervertebral disc.
Nature
Throbbing
pain associated with sweats and chills may be an infection.
Deep
boring pain, which wakes the patient from sleep, may be caused by a tumour.
Similarly,
dysfunction needs to be explored carefully to see whether it is caused by
weakness, pain, instability, locking or even lack of confidence.
History
for surgery
If surgery is a possibility you need to know whether it would be safe
before you offer it as a treatment option. This can be divided into two
sections. The first is identification of conditions, which increase the risk of
anaesthesia and of surgery morbidity. The second involves determining whether
Factors
in the history which point to high-risk patients are:
• patients who have had problems with previous anaesthetics;
• a history of cardiac or circulatory problems — previous
myocardial infarcts, angina, cardiac arrhythmias, high blood pressure,
peripheral vascular disease, previous strokes or transient ischaemic attacks;
• breathing problems — chronic breathing problems such as
asthma or chronic bronchitis. Acute problems such as chest infection;
• metabolic problems — diabetes and steroid treatment;
• urinary tract problems — benign prostatic hypertrophy which
has not been treated.