My personal perspective from years of working in MSK both in the NHS and private is that taking a good history from your patient not only helps to drive your clinical examinations but often, the patient will give you the majority of the information you need to form a diagnosis.
I’ve been working weekly with undergraduate students this academic year and while it’s clear that clinical pathways and treatment algorithms are excellent for passing exams and attaining qualifications, it is still apparent that there is a fear of MSK or biomechanics in podiatry. I believe this is because when we are learning, while we implement acronyms to help to ensure we’ve covered all aspects of taking a history there’s always one fly in that soup – the patient. The art of history taking is in not letting the patient lead you down avenues that don’t add value to attaining a comprehensive, yet pertinent MSK History.
Always think what the end goal is, and that should be a diagnosis. Sometimes a diagnosis by exclusion, or at the very least a differential diagnosis requiring further investigations.
History taking is an art and needs to be developed rather than learned by rote. That being said the more you do it the better you’ll be at it. This topic has been covered excellently in Podiatry Now in the autumn of 2018 by Cowley and Lepesis and talks about some of the approaches in Physiotherapy and how they cross over into podiatry MSK assessment. It discusses SOAPIER note-taking and valuably suggests;
…that arguably, the clinical history is, arguably the most critical component of any clinical assessment since it aids the podiatrist in determining numerous important factors that will influence both the objective assessment and care planning/goal setting beyond that. These factors include:
- The formation of hypotheses about the diagnosis of the presenting condition.
- Determination of maintaining and/or contributing factors to the presenting condition.
- Determination of the SIN factor (covered in the next article).
- Identification of any clinical or biopsychosocial flags.
- Outlining broad patient and podiatrist agendas and expectations with clear communication.
- Determining some outcome measures for treatment (others may come from the objective assessment).
The history acronym the paper discusses is OLDCARTS which stands for Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Radiation, Temporal Pattern and Severity. I’m sure I used this when I trained, although over the years these questions become part of the ‘art’. At a recent visit to another Podiatry School, I learned that they use OLDCIPPS Common history taking acronyms used in podiatry
| O | Onset | O | Onset |
| L | Location | L | Location |
| D | Duration | D | Duration |
| C | Characteristics | C | Character of pain |
| A | Aggravating/Alleviating factors | I | Impact |
| R | Radiation | P | Progression |
| T | Temporal Pattern | P | Previous treatment |
| S | Severity | A | Associated symptoms |
You can see from the above table, that even here there isn’t a definitive method of extracting all the information from the patient in a structured fashion.
The subjective history taking process is an interview, a conversation with the patient which should also help to establish aims and objectives, and potential barriers to any potential interventions. Essentially, a problem based approach to history taking is what we need rather than ticking off a list of letters of an acronym.
For those that like to visualise this, it can be done in various ways, but visualising where the gaps lie helps to complete the picture. Think of your patient’s history like a jigsaw puzzle.
What is important is getting the first few pieces in place and continuing to fill in the gaps. So get the corners in first, for example:
- Problem
- Location
- Objective
- Pain Scale
Then you start with the sides like:
- When did it start?
- What started it?
- How long has it been hurting for?
What then happens as the patient answers, is that more holes open up in the jigsaw which can open up a new line of questioning that wasn’t there before. Drilling down on particular areas for example
- What do you do for work?
- Are you on your feet at work?
- What footwear for work?
- What features are there in this footwear? Hard/Soft? Heeled/Low? Fastened/Slip-on?
- Do you walk to work?
- Do you walk to work in the same footwear that you use for work?
The thing here is not to be frightened by this next level of discussion as it often leads to homing in on a cause, injured structure, aggravating activity, reason to treat…a diagnosis.
So for anyone who struggles with history taking for MSK patients, I’ve created my version of an MSK history to get you “Jigsaw Thinking”. It highlights questions or topics you might discuss with your patient when completing your jigsaw.
References:
Cowley, E. and Lepesis, V. (2018) The SOAPIER Model in Podiatric Musculoskeletal Assessment and Management: A Three Part Series. (Part 1) Podiatry Now. 21(8), pp.18-20.
Cowley, E. and Lepesis, V. (2018) The SOAPIER Model in Podiatric Musculoskeletal Assessment and Management: A Three Part Series. (Part 2) Podiatry Now. 21(9), pp.8-10.
Cowley, E. and Lepesis, V. (2018) The SOAPIER Model in Podiatric Musculoskeletal Assessment and Management: A Three Part Series. (Part 3) Podiatry Now. 21(10), pp.8-9.
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The more I think about the impact of clinical histort taking the more it seems to feed into so many aspects of MSK, podiatry, other specialisms within podiatry and learing on the undergraduate podiatry journey. When I get the inspirations, I’ll add the articles.