Taking a History of a patient with a Non-traumatic injury

A more wider and thorough approach to history taking is needed than as for a traumatic injury. As well as
taking a detailed history of the presenting complaint, a systematic enquiry is needed. As with taking
a traumatic history, the most important step is the history taking. By taking a thorough and
comprehensive history, the clinician is 60% closer to making a diagnosis. The remaining 40% is a
combination of largely examination findings and also investigations.

With regards to a non-traumatic incident, the patient normally presents with one of four symptoms: pain,
swelling, stiffness and functional disability. It is important to note the pattern of joint involvement.

 Pain
o Site - where exactly is the pain?
o Radiation - does it go anywhere else?
o Nature - can you describe the pain?
o Severity - how bad is the pain?
o Duration - how long have you had the pain?
o Frequency - how often do you get the pain?
o Aggravating factors - what makes the pain worse?
o Relieving factors - what makes the pain worse?
o Related factors - do you get any other symptoms?
 Joint swelling
o Has there been much swelling?
o How much?
o Which joints are affected?
o How long has it been swollen for? (acute or chronic)
 Stiffness
o Is the patient stiff in the morning or evening? (patient's suffering from inflammtory joint
disease are stiff in the morning and improve with activity; patients with osteoarthritis also
have stiffness in the morning but this is usally short-lived)
 Functional disability
o Is there anything you cant do that you used to be able to do? If so why?
 Pain
 Weakness
 Stiffness
 Joint involvement
o Is it monoarticular or polyarticular?
o Is there a characteristic distribution of joint involvement of a particular disease?
o Is there a characteristic time course of a particular disease? (e.g. gout may have one
acute attack followed by man symptom free months)

Systematic Enquiry

 Past medical history - these can be separated into the questions relevant to musculoskeletal
system, those for the different systems in the body and those regarding smoking and alcohol
consumption
o Musculoskeletal
 Any previous similar symptoms?
 Other joints affected?
 Have you noticed any rashes?
 Have you noticed any colour changes with respect to your skin?
 Have you had any problems with your eyes?
 Do you feel cold or warm?
o Systematic enquiry - any symptoms:
 Cardiovascular
 Respiratory
  Gastrointestinal
 Genitourinary
 Neurological
o Smoking and Alcohol comsumption
 Drug history
 Family history
o Any musculoskeletal disorders running in the family?
 Social history
o What job do you do?
o What hobbies do you have? Play any sports?
o Do you drive?
o What sort of housing do you have? Are there any stairs? Are bathroom, bedroom and
toilet upstairs?
o Do you live at home alone or with anyone else?
o Do you use any walking aids?
o Any other assistance?