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
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
