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 second task is to draw out from the patient a full description of those symptoms which confirm one diagnosis, or which exclude others. This is the ‘diagnostic phase’.

  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.

  Summary

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

  The type of pain in particular may give you a clue as to the origin.

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 those conditions have been brought into the best possible control to minimise the risk. Orthopaedic surgery is rarely life-saving, but can be very useful for improving quality of life. It is quite acceptable to take a known risk and operate on a high-risk patient provided that you and the patient are aware of what you are doing. It is quite unacceptable to operate on a patient when either you and/or the patient are not aware of the increased risk, or when the condition has not been brought under the best control possible, and so the patient is being exposed to an unnecessary risk Table 20.4).

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.