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History Taking - basic principles

History taking is the most important step in making a diagnosis. A clinician is 60% closer to making a diagnosis with a thorough history. The remaining 40% is a combination of examination findings and investigations. History taking can either be of a traumatic or non-traumatic injury. The major difference is that the latter involves a wider approach and involves a full systematic enquiry.    

Traumatic

The importance of understanding the mechanism of injury can not be underestimated - it gives clues to the personality of the fracture and the treatment required::

  • When and how did the incident occur?
  • What exactly happened to the limb?
  • How much force was applied?
  • Has the bone or joint ever been damaged before?

Once established, the symptoms secondary to the injury need to be assessed.  

  • Pain
    • Site - where exactly is the pain?
    • Radiation - does it go anywhere else?
    • Nature - can you describe the pain?
    • Severity - how bad is the pain?
    • Duration - how long have you had the pain?
    • Frequency - how often do you get the pain?
    • Aggravating factors - what makes the pain worse?
    • Relieving factors - what makes the pain worse?
    • Related factors - do you get any other symptoms? 
  • Loss of movement
    • Time of loss of movement
    • Was there a dislocation?
    • Are both active and passive range of movements the same?
    • Symptoms of neurological deficit?
    • Symptoms of tendon rupture? (Rupture mainly of biceps and achilles tendons)
  • Instability
    • Has the joint ever given way?
    • Does the joint lock?
    • Does the joint click or clunk?
  • Joint swelling 
    • Has there been much swelling?
    • How much?
    • How soon after the incident?
    • Has it changed?
    • Related features
      • Pain
      • Function 
  • Functional disability
    • Is there anything you cant do that you used to be able to do? If so why?
      • Pain
      • Weakness
      • Stiffness

Non-traumatic



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