Clinical methods of history taking and examination

Published on 11/03/2015 by admin

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Last modified 11/03/2015

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1 Clinical methods of history taking and examination

As in other fields of medicine and surgery, diagnosis of orthopaedic disorders depends first upon an accurate determination of all the abnormal features from:

1 the history
2 clinical examination
3 radiographic examination and other methods of imaging
4 special investigations.

Secondly, it depends upon a correct interpretation of the findings.

HISTORY TAKING

In the diagnosis of orthopaedic conditions the history is often of first importance. In cases of torn meniscus in the knee, for instance, the clinical diagnosis sometimes depends upon the history alone. Except in the most obvious conditions, a detailed history is always required.

First the exact nature of the patient’s complaint is determined. Then the development of the symptoms is traced step by step from their earliest beginning up to the time of the consultation. The patient’s own views on the cause of the symptoms are always worth recording: often they prove to be correct. Enquiry is made into activities that have been found to improve the symptoms or to make them worse, and into the effect of any previous treatment. Facts that often have an important bearing on the condition are the age and present occupation of the patient, previous occupations, hobbies and recreational activities, and previous injuries.

When a full history of the local symptoms has been obtained, do not omit to enquire whether there have been symptoms in other parts of the body, and whether the general health is affected. Ask also about previous illnesses.

Finally, in cases that seem trivial, a tactful enquiry as to why the patient decided to seek advice, and to what extent he is worried by his disability, will often give a valuable clue to the underlying problem. It should be remembered that very often patients seek advice not because they are handicapped by a disability (which is often insignificant) but because they fear the development of some serious disease such as cancer, paralysis, or progressive crippling deformity.

CLINICAL EXAMINATION

The part complained of is examined according to a rigid routine which should become habitual. If this is done, familiarity with the routine will ensure that no step in the examination is forgotten. Accuracy of observation is essential: it can be acquired only by much practice and by diligent attention to detail.

The examination of the part complained of does not complete the clinical examination. It sometimes happens that symptoms felt in one part have their origin in another. For example, pain in the leg is often caused by a lesion in the spine, and pain in the knee may have its origin in the hip. The possibility of a distant lesion must therefore be considered and an examination made of any region under suspicion.

Finally, localised symptoms may be the first or only manifestation of a generalised or widespread disorder. A brief examination is therefore made of the rest of the body with this possibility in mind.

Thus the clinical examination may be considered under three headings:

1 examination of the part complained of
2 investigation of possible sources of referred symptoms
3 general examination of the body as a whole.

1 EXAMINATION OF THE PART COMPLAINED OF

The following description of the steps in the clinical examination is intended only as a guide. The technique of examination will naturally be varied according to individual preference. Nevertheless, it is useful to stick to a particular routine, for a familiarity with it will ensure that no step in the examination is forgotten.

Exposure for examination

It is essential that the part to be examined should be adequately exposed and in a good light. Many mistakes are made simply because the student or practitioner does not insist upon the removal of enough clothes to allow proper examination. When a limb is being examined the sound limb should always be exposed for comparison.

Inspection

Inspection should be carried out systematically, with attention to the following four points:

1 The bones Observe the general alignment and position of the parts to detect any deformity, shortening, or unusual posture.
2 The soft tissues Observe the soft-tissue contours, comparing the two sides. Note any visible evidence of general or local swelling, or of muscle wasting.
3 Colour and texture of the skin Look for redness, cyanosis, pigmentation, shininess, loss of hair, adventitious tufts of hair or other changes.
4 Scars or sinuses If a scar is present, determine from its appearance whether it was caused by operation (linear scar with suture marks), injury (irregular scar), or suppuration (broad, adherent, puckered scar).

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