History Taking for Fracture Case — Question Outline

1. Patient Details

• What is your name?
• How old are you?
• What is your gender / occupation / ethnicity?
• What is your ward / bed number / hospital registration number?

2. Chief Complaint

• "Where do you have pain / swelling / deformity?"
• State: Clinical feature + surface anatomy + duration
  • e.g., "Pain over the right thigh for 2 days"

⚠️ Do NOT write "fracture" as the chief complaint — that is a diagnosis, not a symptom.

3. History of Presenting Illness (HPI)

A. Mechanism of Injury

• How did the injury happen? (fall, road traffic accident, direct blow, twisting?)
• What was the energy of impact?
  • High energy → mechanical/traumatic fracture (young patient, no comorbidity)
  • Low energy → suspect pathological fracture (bone already weakened)
  • Repetitive / routine activity → suspect stress fracture
• What position was the limb in at the time of injury?
• Was there a rotational force? → suggests spiral fracture
• Was there a bending / direct force? → suggests transverse fracture
• Was it a high-speed collision (e.g., MVA, road vs. vehicle)? → suggests comminuted fracture

B. Pain (SOCRATES)

• Site — Where exactly is the pain?
• Onset — When did it start? Sudden or gradual?
• Character — What does it feel like? (sharp, dull, throbbing)
• Radiation — Does it spread anywhere?
• Associated symptoms — Any swelling, deformity, bruising?
• Timing — Constant or intermittent?
• Exacerbating / Relieving factors — What makes it worse or better?
• Severity — Score out of 10

C. Determine the Fracture Characteristics (from history)

• Was there a wound / broken skin over the site? → Open (compound) vs. closed fracture
• Is there visible deformity or shortening of the limb?
• Was there an audible crack at the time of injury?
• Anatomical location — Proximal / midshaft / distal?
• Intra-articular involvement — Is the fracture near or involving a joint?

Example diagnosis formulation: "Right open complete displaced transverse fracture of midshaft femur" or "Left closed comminuted fracture of distal femur with intra-articular involvement of knee joint"

D. Neurovascular Status (ask about associated injuries)

• Any numbness, tingling, or weakness distal to the fracture? (nerve injury)
• Any change in skin colour (pallor, cyanosis) or coldness of the limb? (vascular injury)
• Was there a wound associated? → Assess for open fracture / degloving

4. Associated Symptoms

• Swelling at the site?
• Deformity or abnormal angulation?
• Inability to move the limb / bear weight?
• Any other injuries sustained at the same time? (polytrauma)
• Loss of consciousness at the time of injury?

5. Treatment Received So Far

• Was any first aid or splinting done at the scene?
• Is the patient currently in a POP (plaster of Paris) cast or external fixator? (These are temporary stabilization prior to definitive surgery — ORIF)
• Any analgesia given? What type and dose?
• Was the patient taken to another hospital first?

6. Past Medical History

• Any previous fractures at the same site?
• Any bone diseases — osteoporosis, Paget's disease, bone metastases, osteomalacia? → risk of pathological fracture
• Any metabolic conditions — diabetes, renal failure, liver disease?
• Any malignancy (primary or metastatic)?
• Any prior orthopaedic surgeries or implants?

7. Drug History

• Any steroids (long-term use → osteoporosis)?
• Any NSAIDs? (NSAIDs impair bone healing / non-union risk)
• Any anticoagulants? (important pre-operatively)
• Any bisphosphonates or calcium supplements?
• Any over-the-counter medications or supplements?
• Known drug allergies?

8. Social History

• Smoking — impairs bone healing and wound healing
• Alcohol — risk factor for falls, bone disease, impaired healing
• Occupation — affects rehabilitation planning and return-to-work
• Mobility baseline — was patient independently mobile before the injury? Any walking aids?
• Living situation — lives alone or with family? (important for discharge planning)

9. Family History

• Any family history of osteoporosis, bone tumours, metabolic bone disease?

10. Systems Review

• Cardiovascular: chest pain, palpitations (trauma → haemodynamic compromise)
• Respiratory: shortness of breath (fat embolism after long bone fracture)
• Neurological: any loss of consciousness, confusion?
• Genitourinary: any blood in urine? (pelvic fracture → urethral injury)

Summary Tip from the Article

"The rationale is to understand the mechanism of fracture and to note relevant points in history to arrive at a proximate diagnosis prior to imaging modalities."

• Neurovascular / compartment → Do I need to operate in the next hour or the next day?
• Associated injuries → Is there something more life-threatening than the fracture I can see?
• Pathological fracture / comorbidities → Is the bone already diseased, and will it heal?
• Drug history → Can I safely operate, and is this patient sabotaging their own healing?
• Smoking / alcohol → What is the infection and non-union risk post-operatively?
• Systems review (FES, urethral injury) → What systemic complication should I be anticipating in the next 72 hours?

🔴 Corrections to Your Assessment

1. This is NOT a high energy injury

2. This is NOT a fracture case — you correctly noted this

3. The skin colour change and size increase — these are signs of infection, not vascular injury

• Increased size = swelling from inflammatory oedema / pus collection
• Skin colour change (redness, warmth) = erythema — classic sign of local infection/cellulitis
• Combined with fever on day 4 → this is now a systemic sign — the infection has gone beyond local

✅ So What Is the Working Diagnosis?

📋 How to Correctly Write the Clerking

• Fever — when did it start? How high? (> 38°C suggests systemic infection)
• Is the wound discharging pus?
• Can she bear weight or walk at all?
• Any red streaking going up the leg? (lymphangitis — infection tracking along lymphatic channels toward the groin — surgical emergency)
• Any swelling in the groin? (lymphadenopathy)
• Any rigors or chills?
• Is she eating/drinking normally? (dehydration risk in febrile child)

One Important Flag for You

1. Wound exploration and foreign body removal under anaesthesia (children will not cooperate awake)
2. Debridement of infected tissue
3. IV antibiotics (cover Gram-positive and soil organisms)
4. Wound cultures to guide targeted therapy

History Taking for Diabetic Foot Ulcer (DFU) / Peripheral Arterial Disease

The Core Framework — The "Devil's Triad"

If there is no peripheral neuropathy → think PAD (Peripheral Arterial Disease) instead, confirmed if ischaemic claudication is present.

1. Patient Details

• Name, age, gender, ethnicity, occupation
• Ward / bed number

2. Chief Complaint

• e.g., "Non-healing wound over the right sole for 3 weeks"
• Options: wound / ulcer / pain / swelling / blackening / discharge

⚠️ Do NOT write "diabetic foot ulcer" as the chief complaint — that is a diagnosis.

3. History of Presenting Illness (HPI)

A. Questions on the Wound / Ulcer (Immunopathy — Infection)

1. How long has the wound been present? (non-healing = infection is driving it)
2. Is there pus discharge?
   • Colour, amount, smell? (foul-smelling → anaerobic infection / gangrene)
3. Is there fever?
   • Has it ever fully resolved or does it keep coming back?
   • Did OTC antipyretics or antibiotics give only temporary relief? (suggests deep-seated / persistent infection)
4. How did the wound start?
   • Spontaneous? After a minor trauma (corn removal, nail trimming, stepping on something)?
   • (Minor trauma → neuropathy caused them not to feel the injury in the first place)
5. Has the wound been getting bigger or smaller?
6. Any blackening or discolouration of the toes? (gangrene — a vascular emergency)
7. Any previous history of amputation? (e.g., ray amputation of toe → indicates prior severe DFU)

B. Questions on Peripheral Neuropathy

1. Any numbness or loss of sensation in the feet or legs?
   • "Did you only discover the wound by seeing it, not by feeling pain?" → classic neuropathic presentation
2. Any tingling, burning, or "pins and needles" sensation in the feet? (paraesthesia)
3. Any weakness in the legs?
4. Does the pain/sensation get worse at night? (neuropathic pain classically worse at night)
5. Have you ever had a wound before that you did not notice until it was already infected?

C. Questions on Vasculopathy (PAD — Peripheral Arterial Disease)

1. Intermittent claudication (ischaemia of leg muscles during walking):
   • "Do you get calf pain when walking that forces you to stop and rest, and then it goes away?"
   • Ask for the claudication distance — how far can they walk before pain starts?
   • Does rest relieve the pain? (Yes → intermittent claudication; No → rest pain, more severe)
2. Rest pain (more severe ischaemia):
   • "Do you have pain in the foot or toes even when resting or at night?"
   • "Do you hang your leg off the bed at night to get relief?" (gravity-assisted blood flow = severe PAD)
3. Leriche Syndrome (aortoiliac occlusion — ask if relevant):
   • "Do you have buttock or thigh pain when walking?"
   • "Any weakness of the legs or problems with erection?" (claudication of buttocks + impotence + leg weakness = Leriche syndrome)
4. Risk factors for PAD (atherosclerosis in limb = also in heart and brain):
   • "Have you ever had a heart attack (MI) or chest pain (ACS)?"
   • "Have you ever had a stroke (CVA) or TIA?"
   • "Have you ever had an angiogram (angio) done?"
   • (If plaque forms in coronary or cerebral vessels → very likely also in lower limb vessels)
5. Any discolouration of the toes — purplish or black? (digital ischaemia / dry gangrene)

4. Severity of Diabetes — "Selling the DFU"

The article's key principle: "Only uncontrolled, long-standing diabetes leads to DFU." You must establish this.

Bullet-level indicators of uncontrolled DM:

1. Medications
   • What is the patient taking? Oral medications (metformin, sulphonylureas)? Insulin?
   • (Being on insulin suggests DM was or is uncontrolled — oral drugs were insufficient)
2. HbA1c value
   • "Do you have a diabetes book (follow-up card)? What was your last HbA1c reading?"
   • HbA1c ≥7% = poorly controlled; ≥9% = severely uncontrolled
3. Compliance
   • "Do you take your medications regularly, or do you sometimes skip?"
4. Follow-up
   • "How often do you see your doctor for your diabetes?"
5. Diet
   • "Do you follow a diabetic diet? Or do you eat rice, sugar, sweets freely?"

"Bazooka-level" point (a single positive answer here confirms long-standing uncontrolled DM):

• "Have you ever been referred to an eye specialist (ophthalmologist)?" → Diabetic Retinopathy
• "Have you ever been referred to a kidney specialist (nephrologist)?" → Diabetic Nephropathy
  • (A referral only happens when the managing physician already knows the DM is uncontrolled and long-standing — so this history alone confirms severity)

Glucose monitoring:

• "Do you check your own blood sugar at home?"
• (Only significant if the reading was NOT hypoglycaemic — a high reading confirms poor control)

5. Treatment Received for the Wound

• Any wound dressing done at home or clinic?
• Any antibiotics taken (oral or IV)?
• Any debridement done elsewhere?
• Was the patient previously admitted for the same wound?

6. Past Medical History

• Diabetes mellitus — when was it diagnosed? (duration is key — longer = more complications)
• Type 1 or Type 2?
• Hypertension (accelerates atherosclerosis → worsens PAD)
• Ischaemic heart disease / previous MI
• Chronic kidney disease (diabetic nephropathy — affects drug dosing, surgery risk)
• Previous stroke / TIA
• Previous foot infections or amputations
• Peripheral neuropathy (formally diagnosed?)

7. Drug History

• Current diabetic medications: metformin, sulphonylureas (glipizide, glibenclamide), DPP-4 inhibitors, SGLT-2 inhibitors, insulin?
• Antihypertensives?
• Statins? (used in PAD / cardiovascular risk reduction)
• Antiplatelet agents (aspirin, clopidogrel)? (used in PAD)
• Anticoagulants?
• Any antibiotics already taken for this wound?
• Drug allergies?

8. Social History

• Smoking
  • (Nicotine → vasoconstriction → worsens PAD and healing)
  • (Carboxyhaemoglobin → less oxygen delivery to wound)
  • How many pack-years?
• Alcohol
  • (Inhibits osteoblasts, impairs wound healing, liver disease → poor clotting)
• Occupation / Activity level
  • (Prolonged standing or walking → increased pressure on neuropathic foot → worse ulcer)
• Footwear
  • "Do you usually walk barefoot at home?" (major risk factor — cannot feel pressure points)
  • "What type of shoes do you wear?" (tight shoes → pressure → neuropathic ulcer)
• Mobility / Independence
  • Can the patient walk? Does he use any walking aids?

9. Family History

• Family history of diabetes mellitus
• Family history of cardiovascular disease / PAD
• Family history of hypertension

10. Systems Review

Summary: The Logic Behind This History

Neuropathy dominant → felt nothing → wound got deep before noticed
Vasculopathy dominant → poor blood supply → wound won't heal → gangrene risk
Infection dominant → uncontrolled glucose → immune dysfunction → can't clear bacteria

Clinical Analysis: Ms Amna Fakhrina, 6F — Right Sole Puncture Wound

Interpreting Her Current Signs & Symptoms

What is the Most Likely Diagnosis?

"Patients with obvious signs of infection within a few days of a puncture wound usually have a simple cellulitis (with or without a foreign body) with a gram-positive organism. In a study of 80 children with plantar puncture wounds and signs of infection, simple cellulitis was found in 59, retained foreign bodies in 11, and osteomyelitis or septic arthritis in 10 children." — Roberts & Hedges' Clinical Procedures in Emergency Medicine

• ~74% simple cellulitis (± retained FB)
• ~14% retained foreign body
• ~12% osteomyelitis or septic arthritis

🔴 What You Must Urgently Rule Out

1. Deep Space Infection / Abscess of the Foot

2. Osteomyelitis

"In a patient with persistent pain or swelling days to weeks after a puncture wound, the presence or absence of deep soft tissue infection or low-grade osteomyelitis cannot be ruled in or ruled out by physical examination, plain radiographs, or laboratory tests alone." — Roberts & Hedges'

• Wood is radiolucent → does NOT show up on plain X-ray
• Wood is organic → introduces soil bacteria directly into deep tissue
• The most feared organism in plantar puncture wounds through a shoe (or soil) is Pseudomonas aeruginosa → causes aggressive osteomyelitis
• In a barefoot child on grass, also consider Staphylococcus aureus and Streptococcus

• Limping (deep bony pain)
• Persisting for 4 days post-injury
• Retained foreign body not removed
• Low-grade fever not resolving

3. Septic Arthritis

✅ Good News From Her Negatives

What Needs to Happen Now

How to Document This in Your Clerking

What You Have ✅ vs What You Missed ❌

✅ What You Covered

❌ What You Missed

1. HPI — Pain Detail (SOCRATES not completed)

• Character — Is the pain sharp, throbbing, dull, constant?
• Radiation — Does it go anywhere? Up the leg?
• Severity — Score out of 10 (for a 6-year-old, use Wong-Baker FACES scale)
• Timing — Constant or comes and goes? Worse at night?
• Relieving/aggravating factors — Does elevating the foot help? Worse when she walks or even at rest?
• Onset — Was it sharp immediately, or dull at first and got worse over days?

This matters because constant throbbing pain at rest = likely abscess under pressure. Deep bony pain worse on pressing the heel or metatarsals = possible osteomyelitis.

2. HPI — Wound Characteristics (More Detail)

• Exact size of the wound / swelling — has it grown?
• Depth — did the splinter go deep or was it superficial?
• What type of splinter? Wood vs thorn vs glass — wood is radiolucent and organic (high infection risk)
• Was any part of the splinter removed at all, or is the entire piece still inside?
• Colour of the surrounding skin — red (cellulitis) or dark/purple/black (ischaemia/gangrene)?
• Smell of the discharge — foul smell suggests anaerobic infection

3. HPI — Systemic Symptoms (More Completeness)

• How high was the fever? You said 37.8°C — but was it higher at home before coming? Did the mom give paracetamol?
• Duration of fever — started on day 4 only, or was there low-grade fever before?
• Vomiting — febrile children often vomit; also relevant for IV vs oral medication route
• Diarrhoea — dehydration risk in a febrile 6-year-old
• Urinary output — is she urinating normally? (marker of hydration and renal function)
• Activity level — was she still playing on days 1–3, or progressively becoming less active?
• Sleep — is the pain waking her at night? (deep infection / osteomyelitis hallmark)

4. Treatment History (Before Admission)

• Did the mother try to clean the wound at home?
• Any traditional remedies applied to the wound? (common in Malay households — e.g., herbs, oil, paste — can introduce more organisms or delay presentation)
• Any oral antibiotics given by a GP or clinic before coming to hospital?
• Any paracetamol or ibuprofen given for fever/pain? Did it help?
• Was she seen at a clinic or another hospital before this admission?

This is critical — if antibiotics were given, cultures may be negative. If traditional remedies were applied, the wound is potentially more contaminated.

5. Past Medical History

• Any previous infections or hospital admissions?
• Any chronic illness — diabetes (rare at 6 but exists), immunodeficiency, sickle cell disease?
• Any known skin conditions — eczema (breaks skin barrier)?
• Vaccination status — is she up to date? Specifically:
  • Tetanus — a puncture wound from soil in an unvaccinated child = tetanus risk (this is the most critical one to ask in this case)
  • Has she had her standard childhood immunisations?
• Any previous surgery?

The tetanus question is non-negotiable for any penetrating wound. A 6-year-old Malay child in Malaysia should have completed her EPI schedule, but you must confirm.

6. Drug History

• Any regular medications?
• Any known drug allergies? (Essential before prescribing antibiotics)
• Any immunosuppressive medications (steroids, chemotherapy)?

7. Family History

• Any family history of immunodeficiency or recurrent infections?
• Any family history of diabetes mellitus?
• Any family history of bleeding or clotting disorders? (relevant pre-operatively)

8. Social History

• Who does she live with? Parents? Grandparents? Any carers?
• School attendance — is she in school? (contact tracing if infectious condition identified)
• Housing — clean water access, hygienic home environment? (affects wound management at home)
• Socioeconomic background — affects compliance with follow-up and medication access
• Who was supervising her when she was playing barefoot? (not for blame, but for safeguarding — is there adequate supervision at home?)

9. Systems Review

Summary of Gaps

Updated Clinical Picture — Ms Amna Fakhrina, 6F

Pain (SOCRATES — Now Complete)

🔴 Two Findings That Have Just Changed Your Risk Level

1. Pain waking her up at night — This is now osteomyelitis until proven otherwise

In the textbook study of 80 children with plantar puncture wounds: of those with signs of infection, 10 had osteomyelitis or septic arthritis — nearly as many as had retained foreign bodies (11).

• Deep penetrating wooden splinter
• 4-day delay
• Retained until hospital removal
• 9/10 constant throbbing pain
• Limping
• Fever

2. The splinter was removed at hospital — but this does NOT mean the problem is solved

• Form an abscess in the soft tissue
• Track along fascial planes
• Possibly seed into bone (osteomyelitis) or a joint (septic arthritis)

One Thing Still Missing — The Most Important One

Complete Formatted Clerking — Ready to Present

• Respiratory: No cough, no fast breathing
• GI: No vomiting, no diarrhoea — appetite reduced
• Urinary: Normal urine output (hydration maintained)
• Skin: Erythema at wound site only, no other lesions
• General: Reduced activity, pain disrupting sleep

Your Two Remaining Action Points Before the Clerking is Complete

1. Confirm tetanus vaccination status — check the buku kesihatan (health booklet) with the mother
2. Confirm drug allergies — before prescribing antibiotics (penicillin allergy is common)

What This Tells You

Why This Matters for the Clerking

"Following wound debridement and removal of the retained wooden foreign body on Day [X] of admission, the patient's fever, pain, and wound discharge completely resolved. She is currently afebrile, pain-free, and ambulant."

Updated Final Diagnosis Formulation

One Teaching Point From This Case

If infection resolves completely after foreign body removal alone → the foreign body WAS the infection.

Does the Tetanus and Allergy Question Still Apply?

• Tetanus status still needs to be confirmed and documented. A healed wound does not eliminate tetanus risk retroactively — if she was under-vaccinated, a booster may still be required.
• Drug allergy documentation is still needed for the discharge prescription (oral antibiotics are commonly given for a short course post-debridement).

Complete History — Ms Amna Fakhrina bt Fairuz Rahimi

Chief Complaint

History of Presenting Illness

Past Medical History

Drug History

Family History

Social History

Systems Review

• Respiratory: No cough, no difficulty breathing
• GI: No vomiting, no diarrhoea; appetite reduced during illness, now improving
• Urinary: Normal urine output maintained throughout
• Skin: Erythema at wound site only, no other lesions
• General: Reduced activity during illness, now improving post-procedure

Summary