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:

For women:

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

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:

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:

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.

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.

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.