Medical History

The existence of the wound is often so obvious that the importance of a proper medical history is sometimes forgotten9 (Tabje...35:2). The patient's symptoms should be noted, including pain, swelling, paresthesias, and loss of function. It is important to elicit information about the specific mechanism of injury that will either influence treatment or affect outcome. Blunt-force wounds with compressive or tensile forces are more prone to infection. Wounds sustained from contaminated objects or occurring in contaminated environments have increased risk of infection. The most common foreign body in wounds is soil, and the particular composition greatly affects the risk of infection. Clay-containing soils and soils with large amounts of organic material (e.g., swamps) have a high potential for wound infection, whereas sand and black dirt from the highway surface have a low potential. Some body locations have a higher concentration of normal flora and are more prone to infection. For example, most of the surface area of the human body has only a few thousand bacteria per square centimeter, but the perineum, axilla, toe webs, fingernail edges, and intertriginous areas can have over a 1 million/cm2 Animal bite wounds are prone to infection with organisms different than those, which produce infection in nonbite wounds.

A patient should be asked whether the wound was sustained from an intentional act (e.g., assault or self-inflected) or unintentional event. Most states have regulations that require the reporting of intentional injuries, and self-inflicted injuries are grounds for involuntary holding and psychiatric evaluation. Occupational injuries are reportable to the appropriate agency.

The time of the injury and delay in seeking care will influence the decision for primary closure. In experimental models, a delay of more than 3 to 5 h allows the bacterial population to increase to greater than 1 million bacteria per gram of tissue and significantly increases the chances of infection. Treatment performed by a patient before seeking care, or lack thereof, may influence wound appearance. The possibility of a retained foreign body should be assessed by asking about the wounding object and any sensation of an object still in the wound. The presence of a foreign body dramatically increases the potential for infection; experimentally, infection can be initiated with as little as 100 bacteria per gram of tissue.

The impact of the wound on the patient's daily function will vary according to handedness and occupation. Tetanus immunization status should be assessed for every traumatic wound. Allergies will influence treatment with analgesics, anesthetics, antibiotics, and dressings. Patients with a latex allergy must be examined with latex-free gloves.10 Current medications, including those purchased without prescription, should be noted. Patients who are taking warfarin or aspirin may not be able to spontaneously stop bleeding. Lastly, chronic medical conditions that may influence the incidence of wound infection or be associated with poor outcome should be noted. Patients with severe peripheral vascular diseases may not have an adequate blood supply to an injured part of the body for proper healing. Old age can affect healing through debility of a patient's physiology.

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