Method of examining and recording medical cases / by William R. Sanders.

  • Sanders, Bill (William R.)
Date:
1873
Catalogue details

Licence: Public Domain Mark

Credit: Method of examining and recording medical cases / by William R. Sanders. Source: Wellcome Collection.

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    head of diagnosis, is very great. It obviates the vagueness which often arises from the number of details brought out in the Regional examination, and it concentrates the attention on the leading points of the case. IV. Under Prognosis, the immediate result, and the probable remote effects—e.g.^ tendency to relapse, etc.—of the disease should both be considered. V. The principles according to which the Treatment is to be con¬ ducted, and the particular indications, should be noted here ; the direction as to diet and regimen, and a copy of the particular pre¬ scriptions ordered, must also be duly entered. VI. Progress of Case.—The preceding subdivisions include all that can be done at the commencement of a case. So long as a patient continues under treatment, however, renewed observations require to be made. These should be conducted on the same plan —i.e.j of regions and systems—recommended for the first examina¬ tion of the case. Particular attention must be directed to the im¬ portant morbid phenomena summarized under the diagnosis; but, at the same time, a careful lookout should be kept for any important changes or new phenomena which may arise. If well kept, these reports of progress form the most instructive part of the case. VII. Termination of Case.—Before a case is concluded, the pre¬ vious entries should, if time permits, be revised, and any omissions supplied. A careful entry should be made of the state of the patient at the time of dismissal. If the case proves fatal, and an autopsy is held, the report of this should be entered. If the report of the case is kept in a hospital journal or case-book, the reference in the index should be attended to. If the report is a private one, re¬ flections and comments may be added at the end of the case, or may be inserted within brackets under any of the dates, when special phenomena have been observed. Throughout the whole course of the investigation, the results of the observer’s experience, reflection, or reading should be brought to bear on the various incidents as they arise; and although these reflections need not always be explicitly stated, their effect will be apparent in the examination of particular phenomena, or in the modifications made in diagnosis or treatment. Such is an outline of the mode of procedure in the detailed investigation of medical cases. The full examination is especially required in, and adapted for, chronic cases; and as considerable time is required to do it thoroughly, discretion must be used by beginners to avoid vague and irrelevant matter and useless minutise. It is important that the medical observer should be early trained to be expeditious and punctual; to put plain questions, asking one thing at a time; to be expert in manipulation ; to be brief, precise, and simple in narration ; so as not only to save his own time, but