History and Physical as the Best Diagnostic Tool for the Wound Care Clinician

This chapter is an excerpt from Chapter 8: Wound Assessment by Monica Stout and Jayesh Shah, Wound Care Certification Study Guide 3rd Edition, (Best Publishing Company, 3rd quarter, 2021), and Chapter 8: Wound Assessment by Dr. Jayesh Shah, Wound Care Certification Study Guide 2nd edition, Best Publishing Company, 2016. Reprinted with permission of Best Publishing Company.

Even with the technological innovations of the 21st century, history taking still remains the best diagnostic tool and least expensive tool to make a good diagnosis. Recognizing clues from a patient’s history can give important information about the patient’s wound.

The initial step in a wound assessment is to obtain the history of the initial wounding event. A chronological history of the occurrence and progression of the wound, including previous diagnostic testing and treatment interventions, should be obtained and documented. The significance of patient history is shown in Table 1 (general history), Table 2 (social history) and Table 3 (past medical history).

The following questions should be asked:

1. What caused the initial wounding event?

2. Did the wound occur suddenly (trauma, insect bite) or develop gradually over time (neuropathic foot ulcer, venous leg ulcer)?

3. Is this the first wound at this location or a recurrent wound or pattern of wounding?

4. Is the wound painful and, if so, what is the character and nature of the pain?

5. What causes the wound to get better or worse (precipitating or ameliorating factors)?

6. Has the patient had chills, fever, or night sweats?

7. Is there any history of unusual environmental or occupational exposures? Recent travel?

8. Does the patient have a known underlying disease (diabetes mellitus, collagen vascular disease, peripheral arterial occlusive disease, or chronic venous insufficiency), which will be evaluated in more detail during the patient assessment section?

9. What diagnostic studies have already been completed (radiographic or nuclear medicine studies, cultures, biopsies, or vascular studies)?

10. What treatments have been applied (debridements, local wound cleansing and dressings, offloading and protection, compression wraps or devices to control edema, vascular [arterial or venous] surgical or radiographic interventions, hyperbaric oxygen therapy, electrical stimulation, topical growth factors, cellular or tissue-based products, or tertiary interventions)?

11. Has reconstructive surgery been attempted? What were the results of these interventions and were there any complications?

A complete patient history should also include various patient factors like:

1. Mental status or cognitive impairment

2. Age

3. Pain (visual)

4. Position/mobility

5. Comorbidities

6. Ethnicity

7. Social/family support

8. Social issues/alcohol/smoking

9. Nutritional status

Why Is the Wound Not Healing?

An inability to heal may be due to local factors or systemic factors or both.^1-6 Local factors may include:

1. Repeated external trauma because of inappropriate offloading

2. Foot deformity causing abnormal pressure areas

3. Uncontrolled edema

4. Injury from use of toxic substances

5. Inappropriate measures for exudate control

6. Presence of foreign bodies

7. Hematoma formation

8. Undebrided wound/necrotic or non-viable tissue

9. Poor blood supply

10. Hypoxia

11. Bioburden

Systemic factors may include arterial insufficiency or venous insufficiency. Other factors are systemic conditions such as collagen vascular disease, sickle cell disease, hemoglobinopathies, uremia, diabetes, and jaundice. Immunosuppressive drugs, including systemic corticosteroids, anticancer drugs and nonsteroidal anti-inflammatory drugs (NSAIDs), may also be factors. Other systemic factors include immunosuppressive diseases such as HIV, local or systemic malignancy, exposure to radiation, malnutrition, old age, and systemic infection.

Making a Complete Wound Assessment

Perform a complete wound-focused history, a review of systems of the wound patient, and a history-directed physical examination.^1–6 Identify comorbid conditions or contributing underlying medical conditions and other host factors that may limit an effective response to the wound or impact the choice of options for wound treatment. Categorize the wound on the basis of presumed etiology.

Wound assessment should at least include:

1. History of wounding event

2. Wound location (useful in differential diagnosis)

3. Measurement of wound length, width, and depth

4. Appearance of the wound bed

5. Tunneling into the wound bed

6. Exudate quantity and quality

7. Edge of the wound and surrounding skin (periwound)

8. Undermining of the wound edge

9. Assessment of infection

10. Assessment of patient’s pain

11. Wound grading and classification, if applicable

12. Re-evaluation on a periodic basis

Picking Up Clues From the Examination

Attention to clinical clues is a good start, even before touching the wound.⁵ From the patient’s general appearance, one can glean several characteristics.

A cushingoid appearance can indicate corticosteroid use or Addison’s disease. Rheumatoid joints can point toward rheumatoid arthritis or autoimmune disease. Cachexia may indicate the following: malnutrition, dementia, AIDS, cancer, or other infectious etiologies such as tuberculosis.

A face with scleroderma (known as the “purse-string mouth”) may point to calcinosis or Raynaud’s phenomenon. A patient with abnormal affect, posture or facial expression may have factitious disorder. Finally, decreased mobility, facial palsy, masked facies, weakness in one or more extremities may indicate cerebrovascular accident or Parkinson’s disease.

Also consider the appearance of the extremity/extremities.

Edema may indicate venous disease, deep vein thrombosis, lymphedema, congestive heart failure with dependent edema.

International Society of Lymphology (ISL) Classification of Lymphedema

Stage 0:

• Subclinical
• No swelling
• Subjective heaviness or aching

Stage I (Figures 1 and 2):

• Pits on pressure
• Reduced on elevation
• No clinical fibrosis

Stage II (Figure 3):

• Non-pitting
• Not reduced on elevation
• Clinical dermal fibrosis

Stage III (elephantiasis) (Figures 4, 5, and 6):

• Skin thick and leathery
• Hypertrophy of subcutaneous tissues
• Papillomas and verrucous changes
• Massive localized lymphedema

The presence of foot deformities may point toward neuropathic wounds, diabetes with autonomic neuropathy, osteomyelitis, or rheumatoid arthritis.

Cyanosis may indicate arterial disease or Raynaud’s syndrome.

Dependent rubor may reveal arterial disease.

Erythema may indicate infection or contact dermatitis.

Livedo reticularis may point to cholesterol emboli, collagen vascular disease, or cryoglobulinemia.

Sclerodactyly may reveal scleroderma or Raynaud’s disease.

Lipodermatosclerosis/hemosiderin pigmentation may show venous disease.

Eczema/dermatitis may be due to irritation arising from previous treatments.

Jayesh B. Shah is Immediate Past president of the American College of Hyperbaric Medicine and serves as medical director for two wound centers based in San Antonio, TX. In addition, he is president of South Texas Wound Associates, San Antonio. He is also the past president of both the American Association of Physicians of Indian Origin and the Bexar County Medical Society and Current of Board of Trustees of Texas Medical Association.

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References

1. Stout M, Shah JB. Chapter 8, Wound assessment. Shah JB, Milne C. Wound Care Certification Study Guide, 3rd ed. North Palm Beach FL: Best Publishing Company; 2021
2. Shah JB, Wound assessment. Shah JB, Milne C. Wound Care Certification Study Guide, 2nd ed. North Palm Beach FL: Best Publishing Company; 2016
3. Shah JB,Sheffield PJ, Fife C. Textbook of Chronic Wound Care, 1st ed. North Palm Beach FL: Best Publishing Company; 2018
4. Sheffield PJ, Fife CE, editors. Wound Care Practice. 2nd ed. North Palm Beach, FL: Best Publishing Company; 2007; 598.  
5. Kordestani SS. Chapter 4: Wound assessment. In: Kordestani SS (Ed). Atlas of Wound Healing. St. Louis, MO: Elsevier. 2019; 23–29. https://doi.org/10.1016/B978-0-323-67968-8.00004-5.
6. Doughty DB, Sparks B. Chapter 4: Wound healing physiology and factors that affect the repair process. In: Bryant RB, Nix DP (Eds.) Acute and Chronic Wounds: Current Management concepts, 5th ed. St. Louis, MO: Elsevier; 2016.
7. Nix D. Chapter 6: Skin and wound inspection and assessment. In: Bryant RB, Nix DP (Eds.) Acute and Chronic Wounds: Current Management Concepts, 5th ed. St. Louis, MO: Elsevier; 2016.