INTRODUCTION
Look at the patient as he/she walks into the room, this gives an overall picture and sometimes the personality of the patient. Introduce yourself to the patient; ask the name of the patient, accompanying attendees and their relationship. Some patients may feel more shy and embarrassed to talk of their problems in front of others. Patient's inhibition to discuss in front of others must be appreciated, and, if necessary, more private and confidential discussion should be held.
The doctor must be very alert and listen to each and every word the patient says. It is a good practice to document the history as the patient relates it.
The doctor must have lot of patience and perseverance with difficult patients in eliciting history. Conversation should be guided, avoiding any leading questions. The questions should be worded in simple language and patient-understanding of the questions should be ensured.
Always explain to the patient what you are going to do and why you are doing it, in all stages of examination to alleviate anxiety. Eye-to-eye contact, getting attachment to patient's version of the cause and extracting the major problem for which the patient has come today. Patient must be examined gently, without eliciting pain and the environment made comfortable. The doctor should be confident and impressive to the patient, and the patient must feel he/she is in the right place, in safe hands and getting good care.
HISTORY TAKING
Present Complaint
Ask the patient what is his main problem and what made him to come and see you, the duration of each salient complaint must be charted in chronological order.
History of Present Complaint
The full details of the presenting complaint from the time it started must be asked for, the progression of the symptoms, severity, and associated symptoms must be recorded. Quantify the disability due to the problem in terms of day-to-day activities, job related or hobbies and ask the patient what activities he/she cannot do? Questions about the abnormal system or any symptoms of possible diagnosis must be asked for.2
Previous History
This should include any similar problems in the past, illness such as diabetes, hypertension, rheumatism, asthma, allergy, tuberculosis, chest and heart problems, and dyspepsia or peptic ulcer disease (as most of the patients need anti-inflammatory tablets).
Treatment History
Enquire about all the treatments the patient has had including medicines like nonsteroidal anti-inflammatory drugs, steroids, physiotherapy, plasters, orthosis, intra-articular steroid injections, etc. and find out the effect of each treatment. Ask for any allergy to medicines. History of previous surgeries are important.
Family History
Enquire about the general family health, occurrence of any familial or hereditary diseases, and support from the family in terms of psychological and financial aspects.
Social and Occupational History
Marital status, type of place where he/she lives, presence of stairs at home and toilet facilities (Indian or Western toilet—this is important in patients with hip or knee pathology) must be recorded. History of consanguineous marriage is important in the presence of congenital anomalies in their offspring. Exact nature of occupation—sedentary or heavy manual work, the hobbies and the patient's leisure activities must be noted.
Personal History
Alcohol consumption, smoking habits, dietary habits, and sexual life must be recorded. Always quantify the amount of smoking and alcohol intake.
Patient's Expectation
The patients’ expectation is an important factor in the treatment plan. Expectation of each patient is different and sometimes may not be realistic. Some patients might seek an advice just for reassurance rather than for treatment. This must be identified and treated accordingly.
History of Pain
Pain is what the patient feels and tenderness is what the doctor elicits. As pain is an important symptom, which gives a clue to the diagnosis, it must be evaluated in detail.
- Site of pain—localized or diffuse: Ask the patient to denote the maximum point of pain and also the extent of pain.
- Time and mode of onset: It is good to know what triggered the pain at the time of onset and find out what patient was doing at that time. The pain might have begun suddenly or insidiously.
- Severity of pain: This can be assessed in patient's own words as mild, moderate, and severe. Find out whether the patient is able to carry out the daily routine and can perform the job, this again indicates the severity. Does the pain wake-up or keep the patient awake at night or does it force the patient to lie still, this also indicates the severity.
- Nature of pain: It is good to qualify the pain as aching, stabbing, burning, throbbing, constricting or gripping pain, or pricking pain.
- Progression of pain: Has the pain gone worse, remained same, or decreased in time? Is the pain constant or present on and off?
- Aggravating and relieving factors: Ask this question directly to the patient and also document what happens to the pain on joint movements, on walking, standing, body posture, and exercises. Is this pain related to any food intake (e.g., gout)? The relief of pain with analgesics, fomentation, and other means should be noted.
- Patient's opinion on cause of pain: This may throw some light on the cause and also some insight into the patient's problem.
History of Swelling
- First notice: When did the patient notice the swelling or lump (it may not be the time when it first appeared)? Patient might have noticed due to pain or might have noticed at the time of bath, or someone might have pointed it out.
- Symptoms associated with lump: Pain, pressure symptoms—neurological, vascular, or affecting movements of adjacent joints.
- Progression of the lump: Getting bigger or smaller, or disappearing and reappearing in different positions, at different times, etc.
- Any other swelling.
- Patient's opinion on cause of swelling.
Similar sequence is followed in the history of an ulcer.
The history most of the time gives the most probable diagnosis. An experienced clinician modifies the examination by specifically looking for signs that will confirm or refute the provisional diagnosis. If clinical signs do not favor the diagnosis then he returns to the normal routine. But all students must strictly follow the pattern of examination. Also be aware, common problems are common. Do not think of rare diagnosis as we may be rarely right and keep things simple and easy.
CLINICAL EXAMINATION
General Examination
The general examination analyzes the patient as a whole. General build, mental state, presence of anemia, jaundice, cyanosis, clubbing, skin and nail changes (pitting in psoriasis), pedal edema, fever, multiple bone or joint deformities and any generalized manifestation of a disease must be recorded.
Local Examination
Examining the area of symptomatology and examination of appropriate system causing the symptoms add more information of the disease and the possible diagnosis. This follows the foolproof systematic approach of:
- Inspection (look)
- Palpation (feel)
- Movements—active and passive movements. Joint range of movements is measured with goniometer
- Measurements
- Neurovascular status.
Local examination of each part of locomotor system is discussed in detail in subsequent chapters.
Examination of Swelling
- Site
- Size
- Temperature
- Tenderness
- Shape: Hemispherical, oblong, kidney-shaped, pear-shaped, etc.
- Surface: Smooth, irregular, bosselated, or lobular
- Edge: Well-defined and indistinct
Fig. 1: Spreading cellulitis marked by redness, swelling and warmth of skin, and subcutaneous tissue (calor, rubor, dolor, and tumor—signs of inflammation).
- Fluctuation: In cystic swelling, small tense swelling is tested for fluctuation by fixing the swelling's outer margin with one hand and with one finger press on the middle of the swelling to elicit fluctuation—Paget's test. Large cystic swelling should be checked for cross-fluctuation in two planes (right angle to each other) to differentiate from pseudofluctuation in soft swelling like lipoma (Fig. 3)
- Reducibility
- Pulsatility: True expansile pulsations are from aneurysms and vascular tumors. Transmitted pulsations can be felt on swelling over major arteries
- Transillumination: Light will pass through clear fluid. Using a pen torch in a darkroom one can demonstrate a flare in clear fluid-filled sac
- Plane of the swelling: Relationship to surrounding structures—can skin be pinched separately? Swelling deep to muscle becomes less prominent on muscle contraction and difficult to move. Swelling superficial to muscle remains same in size and has free mobility
Fig. 2: Necrotizing fasciitis showing blackening of big toe and blistering of skin due to gangrene with redness proximally.
Fig. 3: Paget's test: Forehead swelling of 2 cm tested for fluctuation by fixing the swelling with examiner's index finger and thumb and with the other hand index finger the center of the swelling was pressed to feel the fluid displacement.
- Fixity: To skin or bone
- Regional lymph nodes
- State of arteries, nerves, bones, and joints.
Examination of Ulcer (Fig. 4)
- Site
- Color
- Warmth
- Tenderness
- Base or floor: It is the surface of the ulcer. It can be of healthy red granulation tissue or gray dead tissue or exposed muscles/tendons
- Edge:
- Sloping edge—in a healing ulcer
- Punched out edge—in trophic ulcer (syphilis, neuropathy, and spina bifida)
- Undermined edge—in tuberculosis
- Rolled out edge—in basal cell carcinoma
- Everted edge—in squamous cell carcinoma
- Depth: The fixity to deep structures is indicated by the mobility of the ulcer
- Discharge: Serous or serosanguinous or purulent
- Regional lymph node
- State of arteries, nerves, bone, and joints.
Examination of Bone and Soft Tissue Tumors
Bone sarcomas are common in children and adolescents while secondaries and myelomas are common in elderly population.
Presenting History
- Pain—onset, duration, nature, aggravating, and relieving factors
- Swelling—onset, duration, progress, change in size, and other swellings
- Pathological fracture—trivial injury causes fracture
- Distant site problems—symptoms from metastasis: Lung symptoms, symptoms of hypercalcemia, or neurological deficit from local spread.
Past History
Any significant medical illness, previous malignancies treated like carcinoma prostate, lung, thyroid, kidney, etc., radioactive isotope treatment or irradiation.
Family History
Hereditary disease like autosomal dominant, von Recklinghausen's disease, diaphyseal aclasis, multiple lipomata, etc.
Personal History
Smoking, alcohol, mental status, and social background.
Occupational History
Exposure to radioactive materials, chemicals, etc.
General Examination
General build, anemia, jaundice, cyanosis, clubbing, and generalized lymphadenopathy.
Systemic Examination
Local Examination (Fig. 5)
Examination of the swelling is done as described before, special points to be noted in tumors are:
- Aggressiveness—a tense rapidly growing tumor with shiny skin, engorged veins, and variable consistency is typical of aggressive tumor
- Skip lesions—look for satellite lesions in the same extremity
- Pressure effects—neurovascular impairment or limitation of range of movements
- Regional lymph node involvement
- Auscultation—listen for a bruit in suspected vascular swellings, telangiectatic osteogenic sarcoma, vascular secondaries, etc.
Origin of tumors in various parts of bone is illustrated in Figure 6.
EXAMINATION OF BONE AND JOINT INFECTION
Acute Osteomyelitis/Joint Sepsis
This is more common in children but can occur in adults who are immunosuppressed or drug addicts. Child who is not well, irritable, having high fever, suddenly not moving the limb (pseudoparalysis) with septic foci in the body should arise high suspicion of acute osteomyelitis or joint sepsis. Joint sepsis is more common in the hip, which presents with inability to move the limb, flexion attitude of the limb, gross restriction of movements with pain and spasm. Patient or parents may attribute it to a fall.
Acute osteomyelitis presents with sudden onset of pain, swelling, inflammation, and loss of function and should be diagnosed clinically.
Fig. 6: Origin of tumors in various parts of bone.(GCT: giant cell tumor; MFH: malignant fibrous histiocytoma)
Both osteomyelitis and joint sepsis should be treated aggressively by investigating full blood count, erythrocyte sedimentation rate (ESR) and blood culture with antibiotics, and, if necessary, emergency surgical drainage. Ultrasound scan may be of good help to establish the diagnosis.
Chronic Osteomyelitis (Figs. 7A and B)
Patient can present with pain, discharging sinus, difficulty in using the limb or weight-bearing in the lower limb, pathological fracture or exuberant growth from ulcer (Marjolin's ulcer).
In the history, onset of first episode, the progress, the treatment taken including various antibiotics and surgical procedures must be taken elaborately. Osteomyelitis starting in childhood will naturally affect the growth of the bone and can cause soft tissue tightness. History of any immunosuppressive disease or drugs (steroids/chemotherapy), smoking, alcohol, diabetes, sickle cell disease, and tuberculosis must be asked for. Enquire about constitutional symptoms, weight loss, etc.
General Examination
General build, anemia, jaundice, cyanosis, generalized lymphadenopathy, and septic focus in the body.
Local Examination
Look: Look for gait (in lower limb involvement), deformity, leg length discrepancy, skin and soft tissue statis ulcer or sinus, puckered scar or wound healed by secondary intention.
Feel: Feel for warmth, tenderness in soft tissue and bones, bony thickening, soft tissue indurations, percussion of bone causes severe pain, abnormal mobility in pathological fracture or infected nonunion, adjacent joints for stiffness and deformity, distal neurovascularity, regional lymph nodes, and other focus of infection.
Move: Test active movements first and then passive movements. Do not attempt movement in an acute infection (very painful). Look for stiffness, abnormal mobility, subluxation, or dislocation in chronic infection.