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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    delirious (I have known a patient in delirium tremens subjected uselessly to a painstaking interrogatory according to a fixed method), or if he is in a weak or dangerous condition, those circumstances should be reported, and the course of examination modified ac¬ cordingly. To this precaution the physician or his assistant usually attends, but it is well that beginners should also be aware of it. I. Preliminary Information, which is the first division, com¬ prises :—• 1 stj The designation, i.e., name, age, occupation, etc., date of admission [giving day of month and year), etc. 2c?, Complaints of patient: f.e., a brief statement of all his alleged ailments. This information is usually derived from the patient himself. If his complaints are definite, e.#., u complains of cough,” u looseness of the bowels,” etc., these are set down simply : but if his symptoms are vague, we must say so, and endeavour to ascertain cursorily, whether his ailments are general or local, as indicated by pain, etc. Sometimes it is told us on the part of friends, previous medical attendant, or by the patient himself, that his case is one of u heart disease,” u diabetes,” etc. When thus obtained, the information should be entered upon as u Reported (by-) to be suffering from,” etc. Occasionally a patient is admitted, who is seen at once to be affected with u jaundice,” etc., which fact may at once be set down, along with his other com¬ plaints. Lastly, patients may be brought in comatose,—or in a fit, or delirious, etc. Unusual circumstances like these, require of course modifications in the statement, which are suggested by the events themselves. All that is wanted at this stage, is a first indication as to the probable nature of the case, so as to guide the further examination, on which alone, and not on first impressions, the diagnosis must be founded. 3c?, Antecedent History (Anamnesis). This includes, first and chiefly, the account of the present attack, its presumed cause, date of commencement, first symptoms, and subsequent course, till the time of admission. Next, the previous state of health, and especially former diseases, are noted. Inquiry may then be made as to the social condition and habits (clothing, lodging, food, intemperance, syphilis, mercury, etc.); and, lastly, any important particulars of family history, as to hereditary diseases and general health or longevity, may be taken down. In regard to etiology, diagnosis, and prognosis, the history or anamnesis is of great importance. But it is a very difficult part of case-taking, owing to the want of recollection or the deficient powers of observation or description on the part of the patient. Here patience, and especially tact in eliciting reliable facts and dates, with succinctness in narration, are qualities which the observer ought to cultivate. In the course of careful case-taking, a doubt may sometimes