Case history

Observe the patient entering the room. Notice their gait and attitude. Detailed assessment of gait may be required. Observe the patients posture, face, speech, body language and manner and actions during the case history for defects, pigmentations, anaemia, jaundice, fidgeting and nervous behaviour.

Basic information: full name, address, telephone number, date of birth/age (prone to types of pathologies), status (single, married, de facto, gay), occupation (body use, financial, stressors), ethnic origin (cultures express illness in different ways), referred by (may need feedback or polite thank you).

Main symptom/complaint (not a disease label), site (specific or general), character (pain, dizziness, pins and needles), severity (numb, ache, sharp pain), duration (when did it start? is it acute, sub-acute or chronic?), how did it start? (quickly or gradually?), aggravating factors (is it worse morning/evening, after exercise, rest, when sitting/standing/lying down?), relieving factors (ie rest, heat/cold, self help), other signs and symptoms (are they associated with the main symptom, local or referred). How are the patient's energy levels?

Past history of main complaint, other major illnesses, infections, surgery, falls, fractures, accidents, allergies, and previous treatments.  Accident history - when, where and how, treatment given. Direction and speed of force, awareness (un/conscious), position and response. By now you should be aware of the patients attitude to their illness. Family history (brothers, sisters and parents health/cause of death). Congenital/inherited factors such as cervical ribs, extra or missing vertebrae or muscle attachments, hip deformities. Personal and social history - background of family life and social interests if appropriate. Work - hours, stress/stimulation, dangers, posture, active/sedentary, and economic circumstances. Environmental - home (heating, ventilation, garden), holidays or frequency of breaks.

Psychoemotional - stress (too much/little, is source internal/worry or external, management skills), personality (cheerful, anxious, depressed), relationships, history of mental illness (behavioural or organic).

Medication (past or present, side effects, compound effect).

Present diet - Breakfast, Lunch, Dinner, Snacks, idiosyncrasies, allergies. Does diet fulfil needs for energy, protein (structure), nutrients (vitamins and minerals) and fibre (bulk). Consider the quality of the food, the quantity eaten and time it is eaten. Is the patient able to assimilate, digest, transport, metabolise their food and eliminate their waste? How is the patient's appetite?

Postural - how long does patient spend each day standing, sitting, reclining, and working in unusual positions or on one weight bearing side? Consider their furniture, mattress, sleeping positions, bad habits.

Exercise/activities. Optimally we require a balanced programme of stretching, strengthening, aerobics and skill development. Find out what patient enjoys and if possible use it.

Habits - tea, coffee, sugar, alcohol, tobacco, other drugs, sleep, supplements, medication ie laxatives, sedatives.

Enquirer as to general health, skin, frequency of colds or influenza, bowel action, urine frequency, weight gain/loss.

Record a general evaluation of health - poor, moderate, good, excellent.

Physical examination

Look! You need good lighting. Palpate. Compare symmetry. Vital signs. Blood pressure (120/80), weight, height, pulse rate (70-80 beats per minute), respiratory rate (15 breaths per minute), temperature (36.9 deg C).

In the examination we need to consider the interrelations between the various structures (including mind and body), identify and remove the cause of the problem and screen out serious conditions which need referral. The wholistic approach should be adopted but we should be cautious to exercise discrimination if we are not to be side tracked examining irrelevant tissues and waste the patient's time and money.

Always examine the area of localised pain or symptom and examine other areas if the problem is referred, compensatory or chronic.

The Structural analysis

• Posterior view - note symmetry of:
  • head carriage,
  • shoulder heights,
  • scapula bony landmarks
  • arm distance from side
  • rotoscoliosis
  • muscle atrophy and hypertrophy
  • skin folds at the waist
  • pelvic bony landmarks
  • skin folds at the buttocks
  • skin folds at the knees
  • valgus or varus of knees
  • valgus or varus of ankles
    
    
• Lateral view - note:
  • head carriage
  • scapula winging
  • anterior-posterior distribution of body
  • kyphosis
  • visceroptosis
  • lordosis
  • increased lumbosacral angle
  • pelvic tilt
  • knee hyperextension
    
    
• Anterior view - note symmetry of:
  • face
  • head carriage
  • shoulder heights
  • clavicles
  • arm distance from side
  • muscle atrophy and hypertrophy
  • ribs
  • sideshifting of trunk
  • skin folds at the waist
  • pelvis
  • patella/ valgus or varus of knees
  • placement of feet
  • arches of feet
    
    
• Gait  The two phases of walking are: .

  1. Stance (60%)	2. Swing (40%)
  which includes
  a)heel strike	a)acceleration
  b)flat foot	b)midswing
  c)midstance	c)deceleration
  d)push off

Ask yourself 'In which phase does the problem occur'? Most occur in the weight bearing stance phase. If there is pain and pathology the time spent on the weight bearing leg and the length of the patients stride decreases.

Painful or antalgic gait may be caused by

• a foot problem such as a heel spur, anterior talofibular ligament strain, fallen arches or a metatarsal stress fracture.
• problems in other joints such as a torn meniscus or ligament damage in the knee or osteoarthritis in the hips or knees.
• a shoe problem. Look for corns on the dorsum of their toes. Check for rough areas inside the shoe.

Painful calluses may develop over the metatarsal heads as a result of fallen transverse arches. Check if the patient wears down the soles and heels of their shoes excessively or unevenly.

Movement should be smooth and involving the whole body. Does the patient lurch from side to side or walk with their feet wide apart? Osteoarthritis or a fused metatarsalphalangeal joint (hallux rigidus) makes hyperextension of the great toe difficult or impossible. Gout may cause pain. Push off may be forced to occur on the side of the foot. Patients whose ankles, knees or hip joints have fused as a result of disease or surgery may have difficulties in all phases of gait, will develop compensations and walk with considerably less energy efficiency.