This document outlines the complete history taking process for musculoskeletal issues of the upper body. It details the key components to include: identifying data, chief complaint, history of present illness, past medical history, medications, allergies, social history, family history, review of systems, and physical examination. The physical examination section describes examining the patient's general appearance, vital signs, inspection, palpation, range of motion assessment, strength testing, and neurovascular assessment. Gathering information in these areas provides a comprehensive understanding of the patient's musculoskeletal issue.

1. Complete History Taking
Musculoskeletal (UPPER)
SHISODIA HARSH VARDHAN SINGH
JONELTA FOUNDATION OF MEDICINE
18-1059-267

2. Identifying Data
• Date and time of history- the data is always important
• Identifying data- age, gender, occupation, marital status
• The source of history or referral can be the patient, a family
member or friend, an officer, a consultant, or the clinical
record.
• Reliability- Document this information, if relevant. This
judgment reflects the quality of the information provided by
the patient and is usually made at the end of the interview.

3. Chief Complaint
• The patient presents with complaints related to their upper musculoskeletal system,
describing pain, discomfort, or functional limitations in one or more areas.

4. History of Present Illness
• The patient describes the onset, duration, and progression of their symptoms in detail.
They explain the location of the pain, the circumstances surrounding its onset (e.g.,
trauma, overuse, gradual onset), and any exacerbating or relieving factors. The patient
may mention any specific activities or movements that aggravate their symptoms, as well
as any previous treatments attempted and their outcomes.

5. Past Medical History
• clinician gathers information about the
patient's past medical conditions,
surgeries, and hospitalizations,
particularly those relevant to the
musculoskeletal system. Specific
attention is given to any previous injuries,
fractures, dislocations, or surgeries
involving the upper extremities or the
shoulder girdle. Information about
chronic medical conditions such as
arthritis, osteoporosis, or systemic
diseases that may affect the
musculoskeletal system is also important.

6. Medications
• The clinician inquires about the
patient's current medications,
including prescription
medications, over-the-counter
drugs, and any recent changes in
medication regimens. Certain
medications, such as
nonsteroidal anti-inflammatory
drugs (NSAIDs) or
corticosteroids, may have
implications for the
musculoskeletal system.

7. Allergies
• The clinician asks about any known allergies to medications, particularly
those commonly used in musculoskeletal conditions, such as antibiotics or
analgesics.

8. Social History
• Information about the patient's occupation, hobbies,
and lifestyle choices is gathered, as these factors can
contribute to the development or exacerbation of
musculoskeletal problems. The clinician explores the
patient's occupational tasks, including repetitive
motions or heavy lifting, as well as any sports or
physical activities the patient engages in.

9. Family History
• A detailed family history is
obtained to identify any familial
musculoskeletal conditions or
hereditary disorders that may
contribute to the patient's
symptoms.

10. Review of Systems
• A comprehensive review of systems is
conducted, paying specific attention to
symptoms related to the
musculoskeletal system, such as joint
pain, swelling, stiffness, weakness, or
limited range of motion. Other relevant
systems, including neurologic,
cardiovascular, and respiratory, are also
assessed to rule out any systemic
involvement.

11. Physical Examination
• General Appearance
The patient's overall appearance, body habitus, and posture
are observed. Signs of pain, deformity, or abnormal movements are noted.
• Vital Signs
The clinician records the patient's blood pressure, heart
rate, respiratory rate, and temperature.
• Inspection
The clinician visually examines the upper musculoskeletal
system, assessing for any visible deformities, swelling, erythema, or skin
changes. They evaluate the patient's overall posture, alignment, and
symmetry of the upper extremities and shoulder girdle.

12. • Palpation
Gentle palpation is performed to identify any
areas of tenderness, swelling, warmth, or palpable
abnormalities, such as bony prominences or masses.
The clinician examines the joints, muscles, tendons,
and ligaments of the upper extremities and shoulder
girdle.
• Range of Motion (ROM) Assessment
Active and passive ROM of
the shoulder, elbow, wrist, and hand joints is
evaluated. The clinician assesses the patient's ability
to perform movements in all planes and notes any
pain, crepitus, or limitations encountered.

13. • Strength Testing
Muscle strength is assessed by having
the patient perform specific movements against
resistance. The clinician evaluates the strength of
major muscle groups in the upper extremities,
comparing both sides for any significant
asymmetry or weakness.
• Neurovascular Assessment
The
clinician evaluates sensory function, assessing for
any abnormalities in light touch.