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History Taking and the Musculoskeletal Examination

 

Introduction

A thorough rheumatologic assessment is performed within the context of a good general evaluation of the patient. The patient should be undressed down to their underwear and in a examination gown. Even regional rheumatic problems require a thorough examination of the patient.

 

Chief Complaint

primary problem of most patients seen by Rheumatology is directly related to pain but there are exceptions. Start with an open ended question like "What brings you to the clinic?" and if an answer is not forthcoming, "Where do you hurt?"

 

History of Present Illness

It is best to get the history in a chronological manner. If the patient chooses to start at the present, let it happen. You can then prompt the patient to go to the onset of their illness and tell their story moving towards the present.

Items of diagnostic significance (and related primarily to pain) include:

  1. Date of onset and type of onset (suddenly or slowly).
  2. Location of pain: (joints, muscles, soft tissues)
  3. Presence of swelling* (before and now)
  4. Subsequent course (progressive, intermittent or remittent).
  5. Present status (better, same or worse).
  6. Impact on their lives. There are four basic spheres of activity:
    • Activities of daily living (ADLs)- dressing, bathing, eating, transfers;
    • Household tasks- cooking, cleaning, washing, gardening, etc.;
    • Employment- physical or sedentary, clerical work ,repetitive tasks;
    • Recreational/hobbies- gardening walking, cycling, etc.
  7. Associated complaints: These are patient’s concerns. The subsequent review of system will systemically touch on broad issues that may shed light on their present illness
  8. Previous management and response: Previous rheumatology care is particularly relevant.
  9. Morning stiffness: Generalized that last for > 30 minutes. This is considered to be an expression of inflammatory arthritis.

 

* The word swelling has different meanings. To the patient, it is a sensation but to the physician it is a visual and tactile experience. Patient’s “swelling” does not correlate readily with the physician’s impression of swelling.

 

Past Medical History

Previous medical problems (ex., hypothyroidism, diabetes mellitus) may be related to the present complaint or influence the rheumatologic management (ex., diabetes mellitus, hypertension). Family History Autoimmune diseases can cluster in a family (hypothyroidism, rheumatoid arthritis, SLE). Gout, ankylosing spondylitis and psoriasis are examples of diseases which can be inherited.

 

Social history

Places the patient's illness in a social context. Management can vary depending on these factors (ex., family support, financial status, personal habits).


Review of systems

Because the causes of pain and arthritis are many, a thorough systems review is important. Clues may be found that can help pinpoint the cause of a rheumatologic disorder.

 

Next Section: Physical Examination