CHAPTER 5 The medical and social history
Introduction
Conditions affecting the lower limb may be caused by, or have ramifications for, the patient’s general health and well-being. The clinician must therefore be aware of the patient’s medical and social history as they may have implications for the diagnosis and management of lower limb problems. Taking a history is a highly skilled exercise and one that requires practice to achieve and maintain competency. Information gleaned from a skilled enquiry is the first step towards making the correct diagnosis, directing further investigations and facilitating the formulation of an appropriate treatment plan. A properly taken medical and social history is concerned with the patient as a whole and not just the lower limb complaint with which the patient has presented. The approach outlined in this chapter forms the basis of a holistic approach to patient care.
Purpose of the medical and social history
History taking is as important as any diagnostic test or physical examination. It is the least expensive of all investigations and time spent on obtaining a thorough history is rarely wasted. Diseases or abnormalities of the lower limb often present with a history of signs and symptoms which will allow the practitioner to make a provisional diagnosis. Once a history has been taken, physical examination and diagnostic tests can then be used to confirm the diagnosis and stage the severity of the condition. A comprehensive history taking therefore initiates the diagnostic process and helps the practitioner to formulate and implement an effective management plan.
An inadequate history of the patient’s health status may have the following consequences:
1. The patient is placed at risk.
With an inadequate knowledge of the patient’s medical history, inappropriate or unsafe treatment may be provided. The actual risk of causing a bacteraemia in a patient with a prosthetic joint (which could infect and then loosen the joint) by performing nail surgery remains unquantified but a theoretical risk certainly exists. Bacteraemia in patients with a history of endocarditis or rheumatic valvular disease may lead to bacterial growth on the previously damaged heart valves or endocardium. Inadequate knowledge of the patient’s existing medication could lead to adverse inter-drug reactions with newly prescribed treatment. If drugs are prescribed (or omitted) in the absence of a detailed medical history, an existing condition may be exacerbated. For example, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) may precipitate asthma attacks.
2. The practitioner is placed at risk.
Inadequate history taking may place the practitioner at risk when handling tissue fluids or products. A history of jaundice should alert the practitioner to the possibility of hepatitis, whereas a history of haemophilia, blood transfusion, foreign travel or intravenous drug use may place the patient – and thus the practitioner – at risk from a blood-borne infection.
Treatment may fail or cause the patient’s presenting condition to worsen because inadequate history taking has prevented accurate diagnosis of the presenting foot complaint. For example, pain and swelling in the calf of a 39-year-old woman, which develops after sport, may be nothing more than local oedema or muscle strain. But if the practitioner finds there is also a history of cigarette smoking, use of the contraceptive pill and recent immobilisation, the differential diagnosis would include deep vein thrombosis, a potentially life-threatening condition that requires quite different management to a pulled muscle.
4. An increased risk of clinical emergencies.
Individuals may be placed at risk by certain treatments, drugs or procedures that are usually considered routine. Adequate history taking will identify those patients who have previously developed adverse reactions. Poor history taking may result in a request for an inappropriate antibiotic prescription from a general practitioner for a patient who is sensitive to penicillin. Hypersensitivity reactions to medicaments (e.g. iodine allergy) or dressings (e.g. zinc oxide strapping) may be known to the patient and should be noted because of the risk of anaphylaxis.
All these factors have implications for cost and litigation.
Format of the medical and social history enquiry
A systematic approach to history taking will ensure that the practitioner covers all relevant areas in the enquiry process. The medical history and systems enquiry presented is based on the hospital assessment or clinical clerking system. Findings recorded with this system (Box 5.1) will determine the need for further clinical or laboratory investigation and indicate the patient’s suitability for a range of treatments.
Box 5.1 The medical history and systems enquiry
Part 3. Personal social history
Part 4. The systems enquiry (CRAGCEL)
Many departments give their patients a health questionnaire to complete (see Appendix 5.1). This can be sent to the patient before the initial visit or, more commonly, before they see the practitioner again. The use of questionnaires gives patients time to consider their answers and reduces the time spent in taking a medical history during the consultation.
Medical history
Current health status
Before history taking begins, the practitioner will gain some impressions about the patient’s current health status from simple observation. Patients should be observed from the moment they enter the consulting room. Diseases of nerves, muscle, bone and joints may be manifested by a patient’s gait or posture. For example, upper and lower motor neurone lesions may cause an ataxic gait, in which coordination and balance are impaired. Patients with acute foot or leg pain will walk with a limp as they try to ‘guard’ the injured part. Patients with chronic foot disorders may shuffle rather than stride because a propulsive gait could cause more pain. Gait disorders in children are best visualised as the child walks into the room to meet the practitioner; children often become self-conscious when asked to walk on demand.
The consultation should begin with a handshake as considerable information can be gleaned from this simple contact. Wasting of the thenar eminence and intrinsic musculature of the hand occurs with rheumatoid arthritis and with some genetic disorders such as Friedreich’s ataxia and Charcot–Marie–Tooth disease. Disorders of skin and nails may manifest themselves in the hand: for example, psoriasis and eczema may cause hypertrophy and anhydrosis of the skin; pulmonary or cyanotic heart disease may cause clubbed or hippocratic nails.
The patient’s facial appearance and expression is also of interest to the practitioner. The tense tired face of those in chronic pain will appear similar to those suffering from depression. Parkinson’s disease or long-term use of psychotropic drugs reduce facial expressions, whereas the thyrotoxic patient, with characteristic protruding eyes, will be striking for their ‘angry’ appearance. Patients on long-term steroid therapy can develop a ‘moon’ face. Hypothyroidism will lead to a loss of hair from the outer third of the eyebrows, baldness, and coarse, thickened facial skin. Acromegaly, in which there is an excess of growth hormone production due to a disorder of the pituitary gland, will give rise to a heavy ‘lantern’ jaw. Cyanotic blue lips are a sign of poor cardiac function. Small plaques of brown lipid under the eyes, seen in hyperlipidaemia, are associated with atherosclerosis.
Weight abnormalities affect the lower limb and should be noted on the first meeting with the patient. Obesity is associated with recalcitrant heel pain and other postural symptoms. Seriously underweight patients may have a range of systemic conditions or they could be poorly nourished due to alcoholism, drug misuse or anorexia nervosa. Fatigue and weight changes are symptoms of many systemic illnesses and are always worthy of note, especially if weight change seems to be rapid.
The following questions will reveal important information about the patient’s general health:
• Are you under the doctor or consultant for any treatment currently?
• Do you feel tired during the day?
In general, patients who are unwell are not good candidates for invasive procedures or treatments that are likely to demand close compliance on their behalf.
Past and current medication
Information about the patient’s previous and current drug therapy can provide useful information about the patient’s health. Patients should be asked if they are currently taking, or have taken in the past, any tablets or other medicines, or if they are using or have used any ointments or creams prescribed by their doctor. It is not uncommon for patients to have taken prescribed drugs for many years with no clear understanding about why they are/were taking them. Refer to the British National Formulary (BNF) or another pharmacological text if you are unfamiliar with any drugs that the patient is taking.
Large doses or prolonged use of certain medications can be associated with significant adverse drug reactions with relevance to the lower limb. Most drugs produce several effects, but the prescriber usually wants a patient to experience only one (or a few) of them; the other effects may be regarded as undesired. Although most people use the term ‘side effect’, the term ‘adverse drug reaction’ is more appropriate for effects that are undesired, unpleasant, noxious or potentially harmful. For example, prednisolone, commonly used in the treatment of rheumatoid arthritis, can reduce skin thickness and impair wound healing. Bendroflumethiazide, a useful diuretic for the treatment of cardiac failure or hypertension, can cause hyperuricaemia, which may result in gout-like symptoms. Warfarin, an oral anticoagulant used for the treatment and prophylaxis of venous thrombosis and pulmonary embolism, increases clotting time and has obvious implications if surgical treatment is planned. Other examples of adverse drug reactions are listed in Table 5.1.
Table 5.1 Adverse effects of drugs affecting the lower limb
| Drug | Therapeutic use | Side effects |
|---|---|---|
| Beta-blockers | Hypertension | Coldness of extremities |
| Calcium channel blockers | Hypertension | Ankle oedema |
| Angiotensin-converting enzyme (ACE) inhibitors | Hypertension | Muscle cramps |
| Propanolol | Hypertension | Paraesthesia |
| Furosemide | Hypertension | Bullous eruptions |
| Salbutamol | Asthma | Peripheral vasodilatation |
| The contraceptive pill | Contraception | Increased risk of deep vein thrombosis |
| Colchicine | Gout | Sensorimotor neuropathy |
| Indometacin | Arthritis | Sensorimotor neuropathy |
| Corticosteroids | Inflammation | Osteoporosis, skin atrophy |
| Aspirin | Pain management | Purpura |
| Metronidazole | Anaerobic infections | Sensorimotor neuropathy |
| 4-quinolones | Infection | Damage to epiphyseal cartilage |
| Chloramphenicol | Infection | Peripheral neuritis |
| Nalidixic acid | Infection | Bullous eruptions |
Patients should also be asked if they are currently taking or have taken in the past any tablets or medicine or used any ointments or creams which they have purchased from a chemist. Self-prescribed medication is of interest to the practitioner not least because the quantities used may be quite variable, with the possibility of chronic overdosing. For example, repeatedly exceeding the recommended daily dosage of vitamins A and D supplements may lead to ectopic calcification in tendon, muscle and periarticular tissue.
The practitioner should be alert to the possibility of a patient developing an allergy or adverse reaction to medications used during treatment. In particular, details of any adverse reactions, either by the patient or any member of the patient’s family, to previous local anaesthetic injections and other drugs (e.g. penicillin) should be sought and explored. A type I hypersensitivity reaction, which may lead to anaphylactic shock, is of most concern. It is not known why some individuals are predisposed to anaphylaxis, though genetic mechanisms are certainly involved since there is a strong familial disposition. In some individuals, contact with certain allergens will stimulate the production of an antibody of the immunoglobulin E (IgE) class, which has the ability to adhere to mast cells in tissues and basophils in the circulation. When an individual sensitised in this way is exposed on a second occasion to the allergen, the allergen combines with the IgE antibodies on the surface of the mast cells. This causes immediate destruction of the mast cell, which releases its contents, specifically histamine, serotonin, platelet-activating factor and slow-reacting substance. If the exposure to the allergen is systemic, hypotension, bronchiole constriction, laryngeal oedema, swelling of the tongue, urticaria, vomiting and diarrhoea may follow. Thankfully, fatal anaphylaxis is rare. When it does occur it usually follows entry of an antigenic drug into the circulation of a sensitised individual. Insect stings are also an important cause of anaphylactic fatality. A local type I hypersensitivity reaction may be caused by local anaesthetic agents but this is rare. In such cases the skin around the area of the injection shows an immediate, localised inflammatory reaction.
Of particular concern to the podiatric practitioner is the potential for overdosage of local anaesthetics, which can lead to convulsions as a result of central nervous system depression. This may be followed by a profound drop in blood pressure and life-threatening cardiovascular depression. In such circumstances oxygen must be administered to support the patient. The risk of such a clinical emergency can be minimised by adhering to the maximum safe dose for the various local anaesthetic agents and always having oxygen available.
Use of recreational drugs should be recorded. Amphetamines, like many mood stimulants, have a vasoconstrictive effect. The use of injectable drugs places the patient at risk of hepatitis and human immunodeficiency virus (HIV) infection. Long-term or heavy use of tobacco can affect wound healing due to the immediate vasoconstrictive effect of nicotine as well as the long-term effects on increased platelet adhesiveness and atherosclerosis. Tobacco smokers are also at greater risk of bronchitis, asthma and lung cancer. Questions to ask are:
Heavy alcohol consumption can affect the peripheral sensation, immune response, postoperative wound healing and the metabolism of local anaesthetics, as well as having implications for treatment compliance. Alcohol consumption is generally measured in units. One unit of alcohol is equivalent to one glass of wine, a single measure of spirits or half a pint of beer. More than four units of alcohol per day is noteworthy. Unfortunately, it is likely that those patients misusing alcohol are least likely to be forthcoming about their alcoholism. Where alcohol misuse is suspected, questions should be asked in a permissive manner. The CAGE system is useful here – two or more positive replies identifies problem drinkers; one is an indication for further enquiry about a person’s drinking. Ask if they:
• have Cut down on drinking – have tried repeatedly without success
• are Annoyed by criticism about drinking habits
• have Guilty feelings about drinking
The patient should also be asked about dry retching in the morning, as this is a symptom of alcohol withdrawal. Drinking before 10 a.m. is an important finding as it is associated with chronic alcoholism.
Past medical history
The past medical history (PMH) consists of information about previous lower limb problems and the treatment received, as well as details about any problems that have affected the patient’s general health. The nature of previous podiatric treatment, the name of the practitioner, details of relevant investigations such as X-rays, and the patient’s view of the treatment’s success should be recorded. This information may prevent the repetition of tests or treatments which have previously been ineffective. The patient should then be asked:
• Have you been off work due to illness for more than 1 week in the past 6 months?
• Have you ever been admitted to hospital?
• Have you ever had an operation?
• Have you ever been under the care of a consultant or a hospital specialist?
These questions will hopefully prompt the patient into recollecting any previous incidents of illness or surgery. Hospital records can provide this information but they are not always available. Questioning should follow a sequence that moves from the patient’s childhood to the present.
Hospitalisations for operations or injuries should be recorded and any complications noted (Case history 5.1). In females, a particularly common procedure is hysterectomy, which has implications for the lower limb in that the effect on hormone balance can lead to premature osteoporosis. This may manifest clinically as vertebral collapse, leading to spinal deformity and possible neural compression. Injuries may often appear to be unrelated to the patient’s presenting complaint but it must be remembered that the lower limb functions as one unit and if one component of the unit is damaged, it can lead to compensations elsewhere in the lower limb. If a patient is still under the care of a hospital consultant it is prudent to inform the consultant before any treatment is given that may affect other body systems.
A 23-year-old secretary presented with pain in the first metatarsophalangeal joint. The pain was aching in nature, severe and worse on exercise. The range of motion of the joint was reduced, with painful crepitus evident on dorsiflexion. Further enquiry elicited a history of trauma from a fall in a horse-riding accident 2 years ago.
Diagnosis: Traumatic arthritis. An X-ray revealed a compression fracture to the head of the first metatarsal, which has predisposed degeneration of the joint.
Family history
A pedigree chart may be used to record details of major illnesses and lower limb problems of the immediate family (Fig. 5.1). Conventions exist regarding the symbols used in the charts. The author’s favourite quote from a patient was that ‘they don’t make old bones in my family!’
Many cardiovascular, alimentary, neurological and endocrine disorders can be inherited and therefore the use of pedigree charts is particularly useful in paediatrics. Enquiry about the medical history of the immediate family may reveal a predisposition to a range of systemic diseases, a good example of which is non-insulin-dependent diabetes. It can also be of value to record the cause of death of immediate family. Certain lower limb pathologies can be inherited or seem to have a familial predisposition, especially diseases that are neurological in nature such as Friedreich’s ataxia and Charcot–Marie–Tooth disease. The diagnosis in a patient presenting with difficulty walking will be influenced by a positive family history of a condition such as these. All forms of spina bifida should be noted even if the problem has been labelled as spina bifida occulta (impaired gait, pes cavus and plantar ulceration have been found to appear late in cases of spina bifida occulta). The patient should be asked if anyone else in the family has suffered from leg or foot problems. This information will help to determine the inherited nature of any foot condition and, in the case of pes cavus, hallux valgus and lesser digit deformity, could indicate the degree of severity that the patient’s presenting condition may eventually achieve.
The ethnic origin of the patient should also be noted. Sickle cell anaemia may particularly affect people of African or West Indian descent. Thalassaemia, another haemolytic anaemia, can affect patients from the Mediterranean and Southeast Asia.
Personal social history
Home circumstances
It is important to consider the patient’s home situation. With some types of treatment patients are required to reduce their activity level to a minimum, change dressings or administer treatments at home. In the case of surgical treatment the practitioner must establish who is going to transport the patient to and from surgery and who is going to assist them through the immediate postoperative recovery period. Lack of home support may rule out certain forms of treatment.
Occupation
A patient’s occupation may be a contributory cause of the lower limb problem and may influence the treatment that can be given (Case history 5.2). Some patients may experience particular difficulties in taking time from work to attend for treatment. The nature of the work should be determined (what they actually do) and special footwear requirements should be noted. The types of surface that the patient stands and walks on during the day can be exciting factors. Bare concrete floors will exacerbate chilblains, whereas patients whose occupation involves standing on ladders will often suffer from chronic medial longitudinal arch pain.
A 27-year-old female sales executive attended the clinic with heel pain. The pain was on the anteromedial aspect of the plantar heel pad and had been present for some time. Point tenderness at the origin of the medial band of the plantar fascia was elicited. Examination revealed a hyperpronatory foot type.
Diagnosis: Plantar fasciitis. However, the patient was required to wear fashionable court shoes for her employment. She was unwilling to compromise on the style of footwear she wore and provision of a suitable orthotic was impossible. The patient was subsequently prescribed stretching exercises and cortisone injections.
Sports and hobbies
Active sportsmen and women may make the association between their sport and a lower limb problem, but those who participate in occasional sporting activities and hobbies may not. Patients who participate in infrequent sporting activities may not think of informing the practitioner of these activities. However, these patients are often more prone to injury because they are often not as fit and do not follow appropriate warm-up and warm-down regimens. These patients are more likely to develop hamstring or calf muscle injury due to poor flexibility – the so-called weekend warrior. Details of any sporting hobby should therefore be sought from the patient. The assessment of the patient with a sports injury is considered in detail in Chapter 15.
Foreign travel
Details of foreign travel should be recorded in case the patient has acquired an infection while abroad. In particular, recent travel to tropical countries and details of any foot injuries sustained while walking barefoot should be recorded (Case history 5.3). Ask if the visit was urban or rural and whether they had any specific vaccinations.
A 23-year-old man attended clinic after 6 months of working as a volunteer in India. For some of the time in India he walked around barefoot and recalls occasionally having to remove splinters and small stones from his sole. He presented with a pruritic, inflamed lesion with a central black dot, under the free edge of the hallucal toe nail of his left foot.
Diagnosis: A tropical parasitic infection with the jigger or sand flea, Tunga penetrans. Originally a native of the New World, it is now widely disseminated in Africa and Asia. A fertilised female, gaining access to human skin, burrows beneath the surface where it becomes engorged with blood. The site of penetration is usually found under the toe nail of the barefooted patient, but can occur on the plantar aspect of the foot. The central black dot is the flea’s abdominal segments. Treatment is by incision and prophylactic antisepsis.
The systems enquiry
The systems enquiry is the key part of the medical history. It seeks to discover if the patient has any systemic conditions, particularly those that may affect the patient’s lower limb problem, and to unearth any signs and symptoms which the patient has not complained of spontaneously. The systems enquiry may reveal significant symptomatology which the practitioner is either inexperienced in or unqualified to diagnose. In such circumstances the patient should be informed that a second opinion is recommended. The subsequent referral for a second opinion should be seen as part of the patient’s overall treatment plan.
All the body systems are worked through in a set order, which can be remembered using the acronym ‘CRAGCEL’ (see Box 5.1). The systems enquiry involves asking questions that will seem, to the patient, to be quite unrelated to the lower limb problem. It is important that patients are advised before the enquiry begins that the purpose of the questions is to ensure that there are no general health problems that may be causing the lower limb condition or that may influence the type of treatment considered.
Cardiovascular system
A history of cardiovascular disease should be taken with respect to systemic, peripheral and haematological disease states, followed up by a review of symptomatology. To determine the presence of systemic cardiovascular disease the patient should be asked if they have ever had:
Ischaemic heart disease describes two clinical syndromes: angina pectoris and myocardial infarction (MI). Angina occurs as a result of atherosclerosis of the arteries to the myocardium and often coexists with atherosclerosis of the arteries to the lower limb. MI is a gross necrosis of the myocardium due to interruption of the blood supply to the area.
Hypertension is a risk factor for many life-threatening conditions such as MI, renal failure and cerebral vascular accidents (strokes). An increase in blood pressure is often asymptomatic and many hypertensive people do not realise they have the condition until they develop symptoms (e.g. transient ischaemic attacks) or routine screening reveals a diastolic blood pressure above 90 mmHg. Practitioners should routinely take their patients’ blood pressure, not least because the stress caused by treatment or examination may provoke a clinical emergency in a patient with uncontrolled hypertension.
Congestive heart failure (CHF) results from the inability of the heart to sufficiently supply oxygenated blood to the tissues. Causes include valvular heart disease, myocardial disease and hypertension (Case history 5.4). Arrhythmias may present as bradycardia (slow heartbeat) or tachycardia (fast heartbeat) with varying degrees of irregularity. Certain rhythms such as ventricular tachycardia predispose to cardiac arrest.
A 65-year-old woman attended the podiatry clinic complaining of weak muscles in her legs. She had noticed the weakness for some time, stating that if her symptoms continued to deteriorate she would have to give up her job as a school playground supervisor. Further questioning revealed that her weakness could more accurately be described as fatigue and heaviness of her legs walking to and from work. The patient had also noticed that climbing stairs causes a tight squeezing pain in her chest. Sitting down relieved the pain but prolonged sitting tended to make her ankles swell.
Diagnosis: Congestive heart failure. This condition can have a direct effect on the ability of the muscles to function under strain.
Rheumatic fever is a febrile disease occurring as a sequel to group A haemolytic streptococcal infections. It is characterised by inflammatory lesions of connective tissue structures, especially of the heart and blood vessels, and predisposes to bacterial endocarditis.
Having recorded disease states of which the patient is aware, enquire further about any systemic cardiovascular symptoms. Ask the patient if they:
The most important cardiovascular symptom to elicit is chest pain (Table 5.2) because of the range of pathologies responsible for its occurrence. The differential diagnosis includes MI, angina pectoris, pneumonia, pericarditis and oesophageal reflux. The pain of angina is tight and pressure-like, precipitated by exercise and relieved by rest, and usually lasts for only a few minutes. The pain in an MI is similar in nature but is much more intense, lasting from 30 minutes to 3 hours.
Table 5.2 Common causes of chest pain
| Cause | Common symptoms | Common signs |
|---|---|---|
| MI | Central, crushing pain that radiates into the arms and jaw. Nausea, vomiting, anxiety and sweating | Pain, sweating, tachycardia |
| Angina | Heavy central chest pain precipitated by activity and stress and relieved by rest | May be absent |
| Pulmonary embolus | Central or pleuritic chest pain. Sudden onset shortness of breath | Tachycardia, tachypnoea, hypotension |
| Pleurisy | Sharp, localised stabbing pain exacerbated by breathing, coughing and movement | Fever |
| Dyspepsia | Central epigastric sharp or burning pain which can radiate to the back | Epigastric tenderness |
| Musculoskeletal | Localised pain exacerbated by breathing, coughing and movement | Localised tenderness |
Dyspnoea (shortness of breath) may occur as a result of pulmonary oedema. In CHF there is an inadequacy in the supply of oxygenated blood. To compensate for this, first the heart rate and then the volume of blood filling the left ventricle increases. Because it takes longer to fill the left ventricle, the pressure in the whole cardiac pulmonary system ‘backs up’, causing pulmonary congestion, reduced blood gas exchange and eventually pulmonary oedema. Pulmonary oedema and shortness of breath are, therefore, signs and symptoms of left-sided heart failure.
Right-sided heart failure is almost always associated with left-sided heart failure and gives rise to peripheral oedema. The right side of the heart can no longer deal with the volume of venous blood returning to the heart for transportation to the lungs and a ‘back up’ of pressure occurs in the systemic circulation, resulting in transudation of fluid into the peripheral connective tissue. Gravity will force most of the transudate to collect bilaterally in the feet and ankles. Initially, the patient will notice that the swelling reduces at night when the legs are recumbent. In chronic right-sided heart failure, the peripheral oedema will eventually be infiltrated by fibrous tissue that cannot be reduced by elevation (non-pitting oedema).
Syncope (fainting) is a transient loss of consciousness. Cardiac disease such as arrhythmias and aortic stenosis can cause syncope by decreasing the cerebral blood supply. Other less-specific systemic cardiac symptoms include fatigue and decreased exertional tolerance.
To determine the presence of peripheral vascular disease the patient should be asked if they have ever had:
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