HUME ON CASE TAKING, WITH AN EXAMPLE.

May, r883.]

ORIGINAL COMMUNICATIONS. CASE TAKING; WITH AN EXAMPLE. By Surgeon T. Hume, m.b., A vircioti.

[This lecture was read to the hospital assistants doing duty under me, and the case chosen as an example is one reported by Mr. Sreenivasa Rao, one of these assistants.] In taking the case of any patient you should invariably follow one course of procedure. By doing so, the sequence of the different points requiring examination becomes so engrained in you, as it were, that in examining any case you will miss no essential point, lesion or condition which will be of assistance to you in coming to The scheme of proceeding a correct diagnosis.

113

number and character of stools, tumours ; liver, percussion, tenderness ; spleen, alterations in size. 5. Respiratory system.?Any alteration in the nasal passages ; larynx, voice ; chest, form, expansion, character and frequency of respiration ; comparative percussion, auscultation, alteration in duration of sounds, accompaniments of sounds

as

crepitation, rales,

vocal resonance; cough, sputum. 6. Circulatory system.?Heart, dulness

frictions

:

precordial

account as second, present illness previous to his coming under With reference to the first, the your care. diseases, and dates at which they occurred, are

percussion, situation of apex beat, palpitations, pain. Auscultation, alterations in first or second sound, any murmur, where heard most distinctly. The guide to the first sound of the heart is the pulse in the carotid artery ; they occur at the same instant. Pulse, character ; arteries, veins and capillaries. 7. Integumentary system.?Eruptions ; perspiration, oedema, hair: nails. 8. Nervous system.?Brain, headache, vertigo, vomiting, coma, sleep, dreams, delirium ; nerves, pain, fatigue, convulsions, tremulousness, numbness, spinal tenderness?by putting a sponge dipped in warm water gently down the back, or by percussion?paralysis, power of feeling. 9. Genitourinary system.?Frequency of micturition ; pain in the back ; quantity of urine ; reaction, specific gravity, albumen, sugar, deposits, microscopic ; uterus, menses, quantity, painful; other discharges, tumour. 10. Locomotor system.?Hypertrophy or atrophy of muscles, power over any diminished.

of great

Bones,

which you must stick to, is as follows :? 1. The heading, which tells the patient's name, age, sex,

condition,

date of admission and

the result. The

general condition of the person ; the temperament, conformation, attitude, expression of face, temperature, respiration, weight, pulse :?here enter what the patient complains 2.

of. 3. Previous history.?This may be divided into two parts, the first being a history of all the ailments the as

distinct

patient an

importance. The more or less the patient's illness, on which narration

has

had ; the possible' of his

ever

second part will be own account of his

on

?

tumours,

inflammations, condition

of

joints.

before you commit

Lymphatic glands.?Neck, groin, axilla,

11.

it to paper,'you will exercise a judicial power as to the relevancy of certain facts, and eliminate

condition.

all unnecessary descriptions of persons, places, and things. Habits, irregularities in diet, ex-

elaborate, especially in the section on the nervous system, yet all essential information

posure to heat or cold, and other circumstances should be noted down. 4. Alimentary system.?Note the condition of the lips, teeth, gums, tongue; then give the character of any eructations,

appetite, thirst, matters.

swallowing,

nausea, vomiting and Pain in abdomen, flatulence,

vomited ascites,

Though

will be

this scheme

might

supplied by following

it

be made

implicitly

more

to en-

able any one to form a correct diagnosis on any case that will present itself however obscure it may

at

first

seem.

The great advantage of plan is, that you have all before you before arriving at

sticking closely

to this

the facts of the

case

a

diagnosis.

Some persons in

taking

a

case

begin

H4

?

THE INDIAN MEDICAL GAZETTE.

by describing the system they imagine to be at fault; and then proceed in a haphazard way through the remaining systems; this I must warn you against, as it tends to make young and inexperienced practitioners rush to conclusions, without having weighed every circumstance of the case in point. There is more chance of your arriving at the modifying circumstances of diathesis and temperament in relation to the special disorder in the particular case, than if you allow yourself to indulge in from one or two statements given

tient,

to

rash guess by the pa-

a

corroborate which you set to looking conditions, and miss some very im-

for certain

portant points which you consider trivial

as

unnecessary for the support of your conceived opinion.

are

As

an

illustration of an

imperfectly taken good example, although

the

they precase

one following is a mein comes even across worse cases, frequently dical periodicals. Ram Lall, male, aged 45 years, a police constable, admitted to hospital on 30th November,

1882 ; case taken on 12th December. Previous history.?This weak and emaciated man

was

admitted

into

hospital on the 30th general dropsy, nearly 45 days

November, 1882, for fever and from which he was suffering for before admission.

By his own statement it that this appears departure from health took place on or about the 15th October last. No previous history of syphilis can be obtained from him.

left than the

right lung. Odour of breath complains of shooting pain in right side, just opposite to the 5th rib.

bearable

:

percussion dulness extends lower

;

mouth

anaemic, teeth parched, lips and gums pale loose, tongue coated with white fur, and moist. Excessive thirst, impaired appetite, feels nausea, and if he vomits, which he occasionally does, it consists of greenish matter; bowels loose and frequent, from 10 to 15 stools in 24 hours, and give out an offensive odour ; colour pale. Respiratory system.?Voice hoarse ; chest flat: the intercostal spaces bulge out during respiration : gets cough which terminates in a free expectoration of a rusty-coloured sputum. Respiration 26 in a minute, and is performed with much difficulty: this being done more by the and

of the

portion

elicits increased with

side, soft,

from

heart

the On

Auscultation the

resonance on

same

and friction sounds.

system.?Pulse full, This

patient

and

quick

minute ;

112 to 120 per

weak.

un-

the middle and

over

right lung.

vocal

crepitation

Circulatory

action of the

cannot

undergo

any prolonged examination, so that I may describe clearly the sounds of this organ. Integumentary system.?Skin rough and hot,

gets

perspiration

no

; there is cedema of the

feet,

and the loose skin round the eyes is puffy. Nervous system.?Restless nights owing to

frequency of the cough, and shortness of breath. Urinary system.?Quantity of urine voided during one whole day is nearly three pints, it is of an alkaline reaction ; specific gravity 1013 : contains albumen ; under the microscope, blood cells, crystals of cystine and bibasic phosphates are seen. Locomotor system.?All the bones of his body and there is much wasting are very prominent, muscularof the system : requires men to help him out of his bed.

Diagnosis.?Bright's pleuro-pneumonia. *

not

disease

followed

breathe unless he

assumes a

by

*

*

*

December.?Motions reduced to 3 ;

i4.th

can-

sitting posture.

the side is very intense, dulness pain lower in the two-thirds of the right lung with in

The

Present condition.?Alimentary system

[May, 1883.

coarse

crepitations The

sanious.

man

;

expectoration putrid

and

the

15th,

died

at

12-30

on

morning. I will

indicate

briefly

omissions in the above attention to

some

all reference

to

some

very

report, and

points

treatment,

in the case, as

it

essential

draw your

omitting

would

make

this lecture too

long. previous history

it is unnecessary to is weak and emaciated ; that is his present condition, and should have been rioted in that heading. No mention is made

In

the

enter that the

man

of the man's temperament, which

was

typical-

SLANE ON MALARIAL CACHEXY.

May, 1883.] ly

nervous ;

bright, restless demeanour, being the

the

glittering,

eyes, as well as the man's evidences of this condition.

The attitude is

unnoticed, although the man had a definite posilying in bed ; he always lay on his

tion while

left side at the time the extreme

in the man's counte-

anxiety depicted

should have formed

nance

The temperature of the

1 he

taken.

was

case

a

man

part of the is

not

notes.

noted ; and

without this paramount guide to fever, you have to remember that in the integumentary system it is said his skin

was

'

hot': in the alimentary '

system that his mouth was parched,' his tongue coated,' and his thirst excessive ': and in the '

4

circulatory that his pulse was '120 per minute,' and still with all this you have 110 idea of the amount of fever the man suffered from. An important omission is the of the ascites from

want

of any

which the

mention suffered.

man

The liver dulness should have been

stated in

inches ; here it was not done I fancy, principally because the Hospital Assistant was puzzled

by

the

hepatised portion

of the

right lung,

and the ascites, making the lines of demarcation not easy of recognition. The character of the

breathing should have been stated, and a more careful description of the lung sounds given. The heart had a haemic murmur. With reference to the diagnosis, I have no doubt that the man's primary disease was Bright's disease,and that the lung complications were consequent to such disease. The pleuro' part of the disease was very slight, and the friction sounds '

noted

are

those sounds in which fine

and friction become

possible

so

crepitation

similar that it is almost im-

to say which is which ; in this case

they the from crepitant, probably judging of the case. A man with Bright's history

were most

final

disease has very small chances of recovery in cases where he is attacked by fever or inflammation ;

and with reference to surgical operait tion, is almost certain death to perform one on him. That this man succumbed with

rapidly

pneumonia,

and that the condition of his

lungs before death became almost gether gangrenous, is not a matter No post-mortem

was

allowed.

if not altofor

surprise.

115

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