History Taking in Orthopedics

A. IDENTIFICATION

1. Age:

<1 yrDevelopmental Dysplasia of Hip (DDH), Cerebral palsy
1-2 yrsNutritional rickets, Poliomyelitis, Ewing’s sarcoma
5-10 yrsTB of hip, Perthe’s disease
< 15Acute osteomyelitis, Juvenile Idiopathic Arthritis
15-20 yrsSlipped Capital Femoral Epiphysis (SCFE)
10-20 yrsBone malignancies, Osteochondroma
30-40 yrsRheumatoid Arthritis
>40 yrsDegenerative disorders, Avascular necrosis, Prolapsed Intervertebral Disc, Multiple myeloma, Metastasis, Gout

2. Gender:

  • Males: Perthe’s disease, SCFE, Traumatic disorders, Multiple myeloma
  • Females: Rheumatoid arthritis, DDH, Osteoporosis, Ankylosing spondylitis, Osteomalacia

3. Occupation: Gives clue to causation and physical requirement

4. Others: Name, Address, Religion, Education, Hobbies, Hand-dominance (Dominant hand commonly affected)

History taking

B. CHIEF COMPLAINTS

What brings patient to the hospital X Duration of complaints (If multiple, must be in the descending order of duration of complaints)

eg. Pain, Difficulty using limb, Inability to walk, Deformity of limb, Swelling, Stiffness, Weakness, Discharging sinus, Altered sensation

 

C. HISTORY OF PRESENTING ILLNESS

a. Diagnostic facts:

  • Present since birth: Congenital
  • During development process: Developmental
  • Fever, chills, rigors, night cries: Infective
  • Nutrition, socio-economic: Metabolic
  • Other evidence of hormonal imbalance: Endocrinal
  • Seasonal variation, inflammatory signs, morning stiffness (>30 min), pain improved with use of affected part: Inflammatory
  • History of Road traffic accident, fall, trauma: Traumatic
  • Advancing age, pain improved by rest and worse with use of affected part/end of the day, locking, instability: Mechanical/Degenerative
  • Constant pain, Night cries, fever, night sweats, anorexia, fatigue, weakness, weight loss, history of Ca. prostate/thyroid/breast/lung/kidney: Neoplastic
  • No obvious complaints: Idiopathic

Note:

  1. Locking: Sudden inability to complete a particular movement
    • Loose bodies
    • Torn meniscus
  2. Unlocking: Offending body slips out of way

b. Pain: Describe in OPQRST

  • Onset: Sudden/Insidious, What triggered? What was patient doing?
  • Progression: Constant? Worsened? Improved? On and off?
    • Neoplasia: Constant pain
    • Trauma: Increases upto 4-6 hours and then decreases
    • Acute Inflammation: Sudden increase and then subsides
    • Chronic inflammation: Remissions and exacerbation of disease
    • New origin pain in painless disease: Malignant change, Pathologic fracture
  • Quality:
    • Aching: Chronic arthritis
    • Stabbing: Ruptured tendon
    • Burning: Neuralgia
    • Throbbing: Abscess
  • Radiation/Referred:
    • Shoulder pain from heart or diaphragm
    • Arm pain from neck
    • Leg pain from back (sciatica)
    • Back pain from kidney, aortic aneurysm, duodenal ulcer
    • Pain may radiate to adjacent sites
  • Relieving and aggravating factors:
    • Direct questions
    • Indirect questions: what happens on joint movements, walking, standing, body posture and exercises
    • Related to any food intake: gout
    • Relief with analgesics, fomentation or other means?
  • Site
  • Severity:
    • Mild: easily ignored
    • Moderate: can’t be ignored, interferes with function and needs attention from time to time
    • Severe: present most time, demanding constant attention or treatment
    • Excruciating: totally incapacitating
  • Timing and Duration

c. Swelling:

  • Onset/first noticed:
    • rapid: hematoma, hemarthrosis
    • slow: inflammation, effusion, infection, tumor
  • Pain:
    • painful: acute inflammation, infection, malignancy
    • painless: benign growth, low grade malignancy
  • Progression:
    • constant or increasing size: neoplastic
    • remission: inflammatory
    • hardens in months: myositis ossificans
  • Swelling at other sites: Neurofibromatosis, Hereditary multiple exostoses, Multiple enchondromas (Ollier’s disease, Maffuci syndrome), Multifocal TB, Polyarthritis
  • Following fracture: Callus formation, Displacement
  • Site:
    • Hand/wrist: Ganglia
    • Foot: Synovial sarcoma
    • Knee: Osteochondroma
    • Greater toe: Gout

d. Limp:

PainfulPainless
TraumaticPoliomyelitis
Inflammatory e.g. TB hipCoxa vara deformity of hip
Osteoarthritis hipDevelopmental dysplasia of hip
Deformity of joint or bone
Fused hip, knee or ankle

 

Coxa-vara (Decreased femoral neck-shaft angle): <120 degrees (Normally 160 degrees at birth and 135 degrees in adult)

  1. Congenital: Growth anomaly at upper femoral epiphysis
  2. Acquired: SCFE, Perthe’s disease, AVN femoral head, Femoral neck fracture, Intertrochanteric fracture, Rickets

e. Deformity:

  • Trauma: Subluxation/dislocation of joint, Malunion, Volkmann Ischemic Contracture
  • Acute painful: Muscle spasm initiated by pain
  • Gradual progression: Chronic infections, Growth-related disorders

f. Stiffness (Joint involvement):

  • Early stages: Muscle spasm
  • Late stages: Adhesions
  • Advanced stages: Ankylosis
Intra-articularExtra-articular
TBMyositis
Septic arthritisArthrogyposis Multiplex Congenita
Viral arthritisBurn contracture
Scleroderma and other such diseases

g. Weakness: loss of muscle power

  • Disuse atrophy of muscle
  • Neurological weakness:
    • Brain: Stroke
    • Spinal cord: Poliomyelitis
    • Nerve: Neuropathy
    • Neuromuscular junction: Myasthenia gravis
    • Muscle: Myopathy
  • Suggestive history:
    • No sensory loss: Myopathy, Motor neuropathy, Polio, Motor neuron disease
    • Sudden: Injury
    • Progressive: Neuropathy, Myopathy
    • Insidious: Myopathy, Leprosy

h. Discharging sinus: Causes of persistent discharging sinus –

  • Diabetes mellitus
  • Chronic osteomyelitis
  • Fungal infection
  • Foreign body
  • Epithelialisation of sinus tract
  • Scar tissue around sinus
  • Malignant change

i. Other things to be asked in HOPI:

  • Activities of daily living (ADL): getting up, sitting down, using bathroom, combing hair
  • Change in sensibility: Intervertebral disc prolapse, local ischemia, peripheral neuropathy
  • Treatment received for the complaint
  • For a case of trauma: Mechanism of injury, Events surrounding the trauma
  • Any need to use ‘aids’?

j. Review of systems: Include only positive history and RELEVANT negative history

 

D. PAST HISTORY

  1. Similar problem on the contralateral side or similar episode previously
  2. Orthopedic history: Injuries, non-surgical treatment, surgery
  3. Medical history:
    1. Twisted ankle: Osteoarthritis
    2. Gastrointestinal disease: Ankylosing spondylitis or Osteoporosis
    3. Conjunctivits, Iritis, Psoriasis, Urogenital disease: Reactive arthritis
    4. Malignancies: Metastatic bone disease
    5. Others: TB, DM, Hypertension, etc.
  4. Surgical history

 

E. PERSONAL HISTORY

  1. Smoking
  2. Alcohol intake
  3. Drug abuse

 

F. FAMILY HISTORY

  1. Orthopedic: Dupuytren’s contracture, Rheumatoid arthritis, Gout, Bone dysplasias may run in families
  2. Medical: TB, DM, HTN

 

G. DRUG AND ALLERGY

  1. Current and past medications
    • Steroids: Avascular necrosis, Problems in wound healing
    • Phenytoin: Dupuytren’s contracture

 

H. SOCIAL HISTORY

  1. Level of care and nutrition in children
  2. Dietary constraints which may cause specific deficiencies
  3. Work practices, travel and recreation

 

I. MENSTRUAL HISTORY (In females):

  1. Menarche: Scoliosis
  2. Menopasue: Osteoporosis

 

J. BIRTH HISTORY

  1. Absence/weakness of fetal movements by 4-5 gestational months: Neuromuscular disease
  2. Maternal Diabetes Mellitus, toxemia, drug ingestion, fetal distress or prematurity
  3. Type of delivery: Breech (DDH)
  4. Physical and mental development of child:
Age (months)Milestones
1-2Holds up chin
6-8Sits alone
8-10Stands with support
10-12Walks with support
14Walks without support
24Ascends stairs one foot at a time

 

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