In inquiry diagnosis in orthopedic and traumatological department, besides collecting the data of general condition of age, occupation, type of work, and the past illness, the stress should be also put on the following aspects.
Chief complaint:
Inquire the main symptoms of the patient and their duration. Chief complaint should reveal the nature of disease and the reason that makes the patient go to seek medical service. The chief symptoms of orthopedic and traumatological patients are pain, swelling, numbness, functional disturbance, deformity, contracture, and paralysis, etc.
Time of onset:
Inquiring the time of trauma or onset is beneficial to determining what the trauma is, new or old, acute or chronic, or some other osteopathy.
Process of onset:
The doctor should inquire in detail about the following: The cause and condition of onset, the nature and strength of violent force, position of trauma; whether there was coma and the duration of coma; whether there occurred coma again after resuscitation; whether there was bleeding and the volume of bleeding; whether emergency treatment was given on the spot and what was the result; and what are the present symptoms and the severity.
Generally, trauma in everyday life is mild; but industrial, agricultural and traffic accident traumas are serious, they are often compound or serious crush traumas. If the patient was falling from high place with heel first touching the ground, then he may get trauma in spine, heel or base of skull. Inquiring the cause and the position of trauma is helpful for judging the condition of trauma.
Traumatic condition:
This aims to inquire the region of trauma and the local symptoms.
Pain:
Inquire the region, time, range, severity and nature of the pain, i.e., is it sharp, or distending, or aching, or stabbing pain, persistent or episodic? What are the factors aggravating the pain? Whether there is referred pain, radiating pain and numbness.
Swelling:
Inquire about the time, region, extent and range of the swelling. In traumatic disorders, usually pain goes before swelling; and in infectious disorders, swelling usually goes before pain or with local fever. If there is local mass, whether the mass is growing and how fast it grows should be inquired.
Functions of the limb:
Inquire whether there is functional disturbance. If there is, did it appear immediately after the trauma or gradually? Generally, at the time dislocation or fracture occurs, the function is immediately lost in most cases. In the case of soft tissue injury, it takes a period of time for a hematoma to develop gradually to affect the function of the limb.
Deformity:
Inquire about the time of occurrence of the deformity and its developing process. Mter trauma, there may appear deformity immediately, or several years later. If there is no trauma, congenital or developmental factors or other osteopathies should be considered for a deformity.
Open wound:
Inquire the time the opening of wound develops, the environment where the trauma occurs, the condition of bleeding, the process of treatment and whether antitetanic serum is used.