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2. History of Present Illness (HPI)
o Provides a chronological narrative of symptoms and events leading to the current
condition.
o Includes details on:
▪ Onset: When and how the symptoms started (acute vs. chronic onset).
▪ Location: Specific anatomical area affected.
▪ Duration: How long symptoms have been present.
▪ Character: Description of pain (sharp, dull, throbbing, burning).
▪ Aggravating/Relieving Factors: Movements, activities, or treatments that
worsen or alleviate symptoms.
▪ Associated Symptoms: Presence of swelling, redness, numbness,
tingling, or functional impairment.
▪ Mechanism of Injury: For traumatic cases, determine the exact
circumstances (e.g., fall, direct blow, twisting injury).
3. Past Medical History (PMH)
o Identifies pre-existing conditions that may impact orthopaedic health, such as:
▪ Osteoporosis
▪ Rheumatoid arthritis
▪ Diabetes (which can affect healing and sensation)
▪ Neuromuscular disorders
o Prior hospitalizations, surgeries, or injuries related to musculoskeletal health.
4. Medications and Allergies
o List of all current medications, including:
▪ Prescription drugs
▪ Over-the-counter medications
▪ Herbal supplements
o Special attention to medications affecting musculoskeletal function, such as
corticosteroids or anticoagulants.
o Allergies to medications (e.g., NSAIDs, antibiotics) or materials (e.g., latex,
adhesives).
5. Family History
o Identifies hereditary conditions that may influence diagnosis or treatment, such
as:
▪ Osteogenesis imperfecta
▪ Marfan syndrome
▪ Ehlers-Danlos syndrome
▪ Genetic predisposition to arthritis or osteoporosis
6. Social History
o Provides insight into lifestyle factors affecting musculoskeletal health:
▪ Occupation: Physical demands of work, repetitive motions, prolonged
standing or lifting.
▪ Recreational Activities: Participation in sports, high-impact activities, or
hobbies that may contribute to injuries.
▪ Smoking and Alcohol Use: Potential impact on bone health and healing
processes.