The first step is a closed-ended question and answer format in which the patient answers direct, pointed questions. This step can be accomplished in a written form that the patient fills out.

After the closed-ended history is complete, the patient and examiner should engage in an open dialog to discuss the patient’s condition. A closed-ended history may lead the examiner to the patient’s problem but may not address the patient’s fears or concerns regarding this condition. The patient may also have other problems either directly or indirectly related to the presenting complaint that may not be addressed by a closed-ended history.

An open-ended history may take on a discussion format in which the examiner and patient ask questions of each other. In this way, the examiner acquires extra needed information about the patient and the patient’s complaint. All aspects of the patient’s complaint should be explored and evaluated to its fullest. The examiner should develop a good rapport with the patient, keeping the patient focused on the presenting problem and discouraging irrelevant topics. The pneumonic OPQRST (onset, provoking or palliative concerns, quality of pain, radiating, site and severity, time) may be incorporated into this evaluation (Box 1-3).

Once the examiner has determined all aspects of the presenting complaint, it is time to focus on the history. Has the patient had prior problems with this or any other complaint? This information may assist with both assessment of the problem and insight on how to treat the problem.

Family history can give a clue about the patient’s propensity of inheriting familial diseases. A significant number of neurologic problems and many orthopaedic problems can be traced to family members.

Occupational and social histories are also important because they may lead to a factor causing the patient’s problem, such as an overuse syndrome. They can also help to determine whether the patient’s condition will respond more favorably if the patient refrains from performing certain work or social functions. For example, lifting, bending, and playing tennis or golf may be contraindicated. The patient may also need to be retrained for other types of work.

Skin assessment should begin with common and obvious findings, such as bruising, scarring, and evidence of trauma or surgery. Then look for changes in color, either from vascular changes accompanying inflammation or from vascular deficiency, such as pallor or cyanosis. Large, brownish, pigmented areas and/or hairy regions, especially on or near the spine, may indicate a bony defect such as spina bifida. Changes in texture may accompany reflex sympathetic dystrophies. Open wounds should be evaluated for either traumatic or insidious origin, which may accompany diabetes.

Subcutaneous soft tissue abnormalities usually involve either inflammation and swelling or atrophy. When evaluating for an increase in size, attempt to identify edema, articular effusion, muscle hypertrophy, or other hypertrophic changes. Also note any nodules, lymph nodes, or cysts. Establish any inflammation by comparing bilateral symmetry for the torso and circumferential measurements for the extremities.

Bony structure should be evaluated, especially when the patient presents with a functional abnormality, such as a gait deviance or an altered range of motion. Bony inspection in the spine should focus on items such as scoliosis, pelvic tilt, and shoulder height. Note and possibly measure malformations in the extremities that may be congenital or traumatic. Two examples of congenital malformations are genu varus and genu valgus. Traumatic malformations include a healed Colles’ fracture with residual angulation. All bony structures should be visually assessed for abnormalities and documented.

Gait analysis is important in assessing neurological and/or musculoskeletal dysfunction. Gait is an important aspect of inspection which may lead you to specific diagnostic conclusions. Gait is particular to each individual, although there are normal characteristics of gait, deviation of normal may not necessarily be pathologic. Dysfunctional gait patterns noted during inspection may lead to an expedited diagnosis.

A complete gait cycle is a functional event that occurs between the time one foot contacts the ground to the point where the same foot contacts the ground again. The gait cycle consists of two time periods. One is the stance phase which includes the heel strike and flatfoot. This is where the heel strikes the ground and then the forefoot is in contact with the ground resulting with the limb weight bearing. The end of this phase results in the opposite foot leaving the ground. The next time period, is called the swing phase. The swing phase begins with the foot lifted from the ground and ends with the initial contact of the opposite foot striking the ground. Approximately 60% of the gait cycle is in the stance phase and approximately 40% of the gait cycle is in the swing phase. Most gait abnormalities are produced during the stance phase because this is the phase that produces weight bearing.

Evaluate skin temperature first. High skin temperature may indicate an underlying inflammatory process. Low skin temperature may indicate a vascular deficiency. Also, evaluate skin mobility for adhesions, especially after surgery or trauma.

The subcutaneous soft tissue consists of fat, fascia, tendons, muscles, ligaments, joint capsules, nerves, and blood vessels. Palpate these structures with more pressure than for skin. Tenderness is a subjective complaint that should be noted. It may be caused by (a) injury; (b) pathology that correlates directly to the tenderness, such as tenderness at the supraspinatus ligament for supraspinatus tendinitis; or (c) a referred component, such as tenderness in the buttock area from a lumbar injury or pathology. Determine tenderness by applying pressure to the area and grade it according to the patient’s response (Box 1-4).

Evaluate swelling or edema according to its origin. Determine if the inflammation is intra-articular or extra-articular. In intra-articular effusion, the fluid is confined to the joint capsule. In extra-articular effusion, the fluid is in the surrounding tissues. Various palpation techniques are discussed in detail in the chapters on specific areas of the body.

There are different types of swelling or edema, according to onset and palpation feel. If swelling occurs immediately after an injury and feels hard and warm, the swelling contains blood. If the swelling occurs 8 to 24 hours after an injury and feels boggy or spongy, the swelling contains synovial fluid. If the swelling feels tough and dry, it is most likely a callus. If the feeling is thickened or leathery, it is most likely chronic swelling. If the swelling or edema is soft and fluctuating, it is most likely acute. If the feeling is hard, it is most likely bone. If the feeling is thick and slow moving, it is most likely pitting edema.

Pulse amplitude in certain arteries is important. It is used to assess the vascular integrity of an area and plays an integral part in certain tests for thoracic outlet syndrome, arterial insufficiency, and vertebrobasilar compromise.