Clinical Evaluation

Medical History

Much has been written about how to obtain the medical history, but there is a catch: these writings tend to make the most sense only to readers who are experienced enough to no longer need them. In light of this paradox, this book will not say much on the subject; there is no formal chapter on the medical history. Rather, what follows is only a simple list of guidelines. These instructions are an incomplete education, but they are a start.

Introduce yourself. By introducing yourself when you enter the examination room, you bring a necessary human dimension to the initial meeting. It matters little whether you introduce yourself as Jane Smith, Student-Doctor Smith, or some other variation on that theme. What matters is that you remind yourself and the patient that the encounter is personal. You should also repeat the patient’s name, saying it when appropriate during your interview.

Wash your hands. When Semmelweiss introduced the idea that doctors must wash their hands before going from the anatomy laboratory to the obstetricsward, he was ridiculed and shunned. Today,we understand that hand washing prevents infection. Hand washing also helps obtain a good history, I believe: washing your hands in the presence of the patient can help establish trust—you are showing that you respect the patient’s physical space and therefore prepare yourself to enter it. Such a bond will be conducive to the sharing of intimate yet relevant detail. (For instance, you will learn that both gonorrhea and ligament sprains can cause effusions of the knee. A complete history is needed to make the correct diagnosis, and trust in the physician may be needed to obtain that history.) Assume patients always notice whether you do or do not wash your hands.

Sit down. Even if you are short on time, you will seem less hurried if you sit down. As Kurt Vonnegut noted, you become who you pretend to be. If you simply assume the mannerisms of a person who is not in a rush, you will not be rushed. Arguably, the act of sitting transforms you; it actually makes you less hurried.

After asking the patient to speak, listen without interruption for at least 90 seconds. The best way to ensure that the most important medical details are obtained is to allow the patient to tell his or her story. Do not interrupt. If you interrupt the patient, you will probably spend more time obtaining less information—and most patients will not even use the full 90 seconds you give them. This is not so much about good manners as it is about effectiveness. If you think of a pressing question and are afraid you will forget it, scribble a short note to yourself. (I confess that I have trouble with this.)

Find out what the patient wants. In musculoskeletal medicine particularly, your job is to discern mere incidental findings from those that are a source of distress or disability. You must also assess whether the patient is willing to assume the costs, risks, and hassles of treatment. Do not try to cure what is not bothering the patient. For example, many adults have herniated lumbar disks. Your job as diagnostician is not only to diagnose that disk herniation, but also to determine whether there are signs and symptoms attributable to it and whether they are severe enough to warrant treatment. (It is possible that a patient will seek medical attention for back pain only to be reassured that “it’s not cancer.”) Recommending aggressive treatment for asymptomatic and benign abnormalities is foolhardy.

The patient is always right—usually. In most cases, a patient’s story alone will reveal the diagnosis to the perceptive listener. Still, remain aware of the fact that musculoskeletal conditions often produce referred pain, and the area in which the patient reports symptoms is not necessarily the area that harbors the pathology. Hip disease can cause knee area pain; similarly, a proximal nerve injury may be reported as pain in the distal area where that nerve terminates. And, of course, visceral organs can produce musculoskeletal symptoms—a patient who reports left shoulder pain may need a cardiologist, not an orthopaedist.

Collect pearls. Pearls are aphorisms that contain a kernel of medical wisdom. Until you have gained a lot of experience, these pearls may help you take advantage of the experiences of your predecessors—allowing you, in Newton’s phrase, to see further by standing on the shoulders of giants. Pearls help you obtain a history by reminding you to ask the right question or by helping you understand the answers you hear. The best way to collect pearls is to see as many patients as you can. One pearl I still recall from medical school is “posterior shoulder dislocations are associated with seizures and isolated lesser tuberosity fractures of the humerus.” I think I remember this not because I read it, but precisely because that rule helped reveal a subtle tuberosity fracture in a patient I saw.

Obtaining a perfect medical history may be beyond the ability of typical medical students—or even their teachers, for that matter. A reasonable medical history, however, can be obtained by following these rules, and time and experience will only make you better. —Joseph Bernstein, MD, MS

Physical Examination

Medicine is an art, and like all art, it begins with fundamentals. In musculoskeletal medicine, the physical examination is the basis upon which much of clinical practice rests. Although there is certainly a place in musculoskeletal medicine for sophisticated diagnostic tests (or even not-so-sophisticated tests, such as plain radiography), to know when to use these tests and for their results to be meaningful, you must master the art of physical examination.

Certain elements in the patient’s medical history often suggest the diagnosis, and the experienced clinician may be able to pounce on a few short physical examination maneuvers to confirm a diagnosis. The novice, while not as fortunate, has the advantage of not being fooled by too much knowledge. He or she is less likely to omit a seemingly irrelevant test, and in so doing may be able to make a diagnosis otherwise missed.

A beginner can expect to need more time for the examination, not only because each step is slower, but also because more steps will be taken. I urge you to embrace that. The only way to recognize that something is abnormal is to first recognize what is normal; and the best way to do that is to have collected the experience of examining many normal structures.

It may also be helpful to perform a screening musculoskeletal examination on all of your general medical and surgical patients, assessing strength, range of motion, and the absence or presence of pain or swelling in the major joints. The marginal utility of a screening test is fairly low—even if you were to detect an abnormality, it would not be clear from the screening examination alone that abnormality would require treatment. Yet without detecting the abnormality in the first place, a discussion of treatment cannot begin. Thus, fast and easy screening examinations are good for patients. They are also good for novice examiners. Such examinations will allow you to gain facility approaching and making contact with patients. You will also collect a mental database of normal values, which in turn will be invaluable when it comes time to recognizing the abnormal. The enclosed CD has a demonstration of the screening examination, which, as you will see, can be performed expertly in less than 5 Minutes.

All physical examinations begin with inspection. When examining a patient, it is important that you have him or her undress. You will not detect muscle atrophy through a shirt. The examination of a man’s shoulder is the rare instance when I will remain in the room and have the patient disrobe in my presence because important diagnostic information can be gained by watching the coordinated muscle action needed to remove a shirt. For women and all lower extremity examinations, I excuse myself while the patient puts on a gown.

After inspection, the next step is palpation—but before you palpate, make sure you wash your hands, preferably in the patient’s presence. Palpation can be directed to the known surface landmarks, but it may be equally useful to note whether the patient is very tender in areas that do not correspond to discrete structures. Malingering is not uncommon, and tenderness reported in bizarre locations may reflect that. Failing to adequately expose the area under examination is probably the most common mistake in physical diagnosis. The next most common mistake is to terminate the examination prematurely: by ending as soon as one positive finding is encountered, you may fail to detect others. Remember the wisdom of the veterinarians: a dog can have lice and fleas! Finding an abnormality is not a license to stop the examination. Indeed, it is known that some injuries and illnesses come in pairs: a sprained anterior cruciate ligament may be seen in association with a sprain of the medial collateral ligament, for example.

What follows is a collection of physical examination maneuvers. Although the photographs are probably worth a thousand words, viewing pictures of a physical examination is not as good as watching a video, and all forms of passive learning are dwarfed by the experience of examining live people. So please use the information that follows for grounding, but go see patients! —Joseph Bernstein, MD, MS