The first step to every examination is history. Essentially, the patient relates the problem in his or her own words. Questions are asked by the physician to clarify certain points. This is the most important part of the diagnostic procedure. The key elements are:
- Where is the pain or problem?
- When did it begin and how has it progressed?
- What things make it worse/better?
- What treatment, if any, has already been tried, and what was the result?
- What other medical problems do you have?
Next a directed physical exam is done. Part of this exam is to determine how the affected body part differs from normal. Some of the exam is directed at eliciting responses that confirm the problem. Unfortunately, part of this exam may cause minor discomfort. This is not the intent but many orthopaedic problems, especially sports-type injuries, cannot be clearly discerned without examining this type of response. Related parts of the body are also examined.
X-rays are an integral part of the orthopaedic exam. Although many problems do not actually involve the bone, it is important to rule out boney-type abnormalities. Often patients referred by other physicians have already had x-rays taken. These sometimes will suffice; however, special views or updated films are sometimes necessary. During treatment of a problem such as a fracture, follow-up x-rays will be necessary to monitor the progress of the healing. X-rays of the extremities have a very low dose of radiation and their benefits far outweigh their risks. Nonetheless, we try to keep the number of x-rays taken to a minimum. If you are pregnant, be sure to inform the x-ray technician so that appropriate shielding can be used if necessary.
Other studies may be necessary to assist in the diagnosis of the problem. Some of these tests are performed by other specialists. As an example, an MRI scan (Magnetic Resonance Imaging) is sometimes helpful for certain types of problems. It is important to understand, however, that these other tests do not replace a good history and physical exam and some studies show that an MRI scan is less accurate than a history and physical exam by a specialist.
Diagnosis and Differential Diagnosis
Once the examination is complete and the necessary tests have been performed, a “differential diagnosis” is established. This is simply a list of all the possible diagnoses that could explain the patient’s problem. Depending on the nature of the problem, this list may be quite short or relatively long. As an example, in the case of an ankle fracture the list would only have one possible diagnosis on it. However, if the complaint was “knee pain”, the list may include 10 to 15 possible diagnoses.
Given a differential diagnosis, various means are used to narrow down the list. Other tests may be obtained such as blood tests or special imaging studies. Occasionally it is best to just wait and observe a certain condition and time alone will help elucidate the diagnosis. Sometimes a “clinical trial” is done. This is when a diagnosis is presumed and the specific treatment for that problem is administered. If the patient’s response to that treatment is positive, the presumed diagnosis is considered to have been correct. Rarely, a diagnostic surgical procedure is necessary to come to the correct diagnosis, although in such cases, the treatment for the problem is generally performed at the same time.