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