In minutes you can be enjoying one of these tasty snacks
BEANBURGERS DE LUXE
Split, toast and butter hamburger bun, spoon hot baked beans on to each half, and top with a Cheddar De Luxe Slice.
Grill lightly and serve.
for good food and good food ideas
KR68
PAN FRIED SANDWICH
Put a Cheddar De Luxe Slice between 2 slices of bread. Butter the outside of the sandwich and place in
heated frying pan (no oil needed, the butter fries it). Fry both sides. Serve piping hot.
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SPECULUM 1964
3
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must always be stated clearly to put the reader "on the ball" clinically. Medical terms are sometimes preferable to the patient's own words. Make sure that the complaints listed are the significant ones.
Past History.
This is straightforward, but three points may be stressed-
1. The patient's own diagnosis must not be accepted without question.
2. Where a disease in the past may well have a direct effect on the present history it is desirable to record briefly the main features as well as the diagnosis.
E.g. Recently a patient was admitted with many of the manifestations of a "collagen disease", with cardiac failure. Six months before the apparent onset she said she had had "acute nephritis", and the student's history noted this as possibly significant.
Enquiry revealed that the main symptoms at that stage had been frequency and scald- ing, and that there was no oedema.
, 3. Where the present illness is known to be preceded by another condition (e.g., rheumatic fever and tonsillitis, tabes dorsalis and primary syphilis), or where predisposing Conditions are known, specific enquiry for such conditions should be recorded.
In many cases it will be necessary to summarise previous in- and out-patient histories, and the investigations performed.
Family History.
The same remarks apply as to past history –7-record enquiries into any aspect of family history which may have a bearing on the present illness, even if negative; e.g., family history of allergy in asthmatics. In hypertensive patient try to elicit a family history of incidents suggestive of hyperten- sion. If the answers are negative say so.
Present Illness.
Do not write a solid closely written page, but paragraph, indent, and underline so that the history may be read and understood easily.
In recording the patient's present illness 'Be following points should be observed- 1. Time Relationships. Give an accurate account of the patient's story, setting out the facts clearly and in chronological order, thus
One month ago--began to get attacks of severe retrosternal pain radiating down left arm.
SP ECULUM 1964
Two weeks ago—first noticed palpita- tions, etc.
Never describe the time of onset as "last September" or "on Tuesday".
2. Mode of Onset. Remember to describe precisely the mode of onset of an illness or a particular symptom.
3. Description of Symptoms. Direct your questions so that you determine the
characteristics of all the important symp- toms, and describe these accurately. Thus if pain is a presenting symptom, its features should be noted: time of onset, mode of onset, location, quality, etc. Only in this way are you likely to be able to determine the origin, cause and signficance of a par- ticular symptom, and convey it to others.
4. Elicit further information. Once you have an outline of the history, and an idea of the likely diagnosis, or at least of which system is affected, further questions should be directed to cover all aspects of the dis- ease involved and to exclude other possible causes of a given symptom complex. Thus a patient with throtoxicosis may present with loss of weight, nervousness, tremor and exophthalmos. A good history will record specifically that there was no diarrhoea, shortness of breath, change in the voice, difficulty in breathing, muscular weakness and so on (and not simply bowels normal, etc.).
Other examples—
Record enquiries re symptoms of
peripheral vascular dis- ease, neuritis, visual disturbance.
haemoptysis, chest pain.
blood loss from each orifice, jaundice, gall- stones, any disease likely to affect the spleen or absorption of essential nutri- ments.
5. Aetiology of Disease. In many cases it will be relevant at this stage to make a more detailed enquiry into possible aetio- logical factors, e.g., contact with toxins, drugs, recent infections, etc.
PAGE FORTY-ONE
Diagnosis
Diabetes mellitus Bronchitis,
Emphysema Anaemia
6. Other Systems. Certain routine ques- tions are designed to cover broadly all other systems (micturition, bowels, digestion, etc.). These may be recorded briefly if they are not likely to be of importance in the particular disease with which you are deal- ing, but if a system may be affected, then the replies to your questions should be recorded in detail, even if these replies are negative. Thus, micturition should be care- fully studied in cases of hypertension, the nervous system in syphilitic heart disease and a history of skin involvement sought in a number of diseases.
7. General Health. You should ascertain the state of the patient's general health by enquiring about his appetite, weight, sleep, etc.
8. A dietary history may be necessary.
Poor nutrition is often an associated or con- tributory factor to disease. A dietary history should be recorded in two parts. Firstly, assess in relation to meals, particularly re protein. Secondly, assess the intake of essential foodstuffs, vitamin and mineral containing foods, and record these as quan- tities per day or week.
e.g., Breakfast Lunch
Afternoon Tea
Milk , Fruit —, Meat —, etc., per day.
Eggs —, Liver , Leafy vegetables —, etc., per week.
Fat and carbohydrate intakes are impor- tant in certain conditions, e.g., diabetes mellitus, spontaneous hypoglycaemia, and obesity.
9. Social History. In most cases it is desirable to obtain some sort of social and psychological history, if only in the course of gaining the patient's confidence. Social factors often have a bearing on aetiology of disease, and influence progress, prognosis and management. The main features are covered by enquiries concerning family life, housing, finance, occupation, education, achievement, and any special problems the patient may have.
It is also instructive to the student to learn from his patients the nature of various occupations and what they entail.
10. Surgical Cases. Patients in surgical wards are likely to be given an anaesthetic and you should therefore record findings which will assist the anaesthetist in deciding whether the patient is a fit subject for anaes- thesia—evidence of pulmonary or cardio- vascular disease, time of last meal in relation to time of accident, etc.
11. Summary. Where the history is long and involved a brief summary of the main features and time relationships is helpful in placing it in perspective. In such cases, make sure that the present condition of the patient is clearly set out.
Physical Examination.
Two common faults in students' histories are-
i. The recording of an abnormal find- ing without details of its characteristics, e.g., "systolic murmur at base", "2 F.B.
liver palpable".
ii. The recording of an abnormal sign without any further reference to it.
An attempt must be made to assess the significance of a physical sign, and in order to interpret a sign you should note all its characteristics and any change in these from time to time. Remember that the initial examination is merely the base-line for further observations in the future.
To assist in this follow-up, quantitative measurements are always valuable. The neck circumference may be measured at the level of the seventh cervical spine posteriorly and the point of maximal convexity anteriorly, in the case of a goitre, before and during treatment. A quantitative petechial count made under standard and repeatable condi- tions is more valuable than the observation
"Hess's test positive". The upper level of dullness or of rales in the chest, the size of the liver (record the upper level, too) and spleen, the girth of the calf or abdomen and many other features are capable of measurement. The grading of heart mur- murs is a similar attempt in this direction.
In all cases, measurements made on ad- mission should be checked again at a later date. It is common to find extraordinary B.P., pulse and temperature values recorded on admission, without any comment in the history or any subsequent check.
PAGE FORTY-TWO SPECULUM 1964
The headings given at the top of the examination sheet are self-explanatory, but are sometimes filled in without any thought, e.g., pulse volume described as poor when E.P. is 200/100, or in a case of rheumatic fever the throat described simply as
"N.A.D." (here the condition of the throat and tonsils should be specifically recorded).
The eyes frequently require more detailed examination than the space allows. Note that the appearance of the patient is always an important "physical sign".
Complete examination of the urine should be done by the student in the ward. If he did it himself instead of copying it up after discharge, the frequent occurrence of album- maria and glycosuria without any further comment would be less common Micro- scopy may be omitted only if there is no likelihood of renal involvement, and a fresh specimen is macroscopically clear and bio- chemically normal.
The method of recording the greater part of the physical examination is largely a matter of personal preference. As with the history, it must readily be understood and readable, with only the accepted abbrevi- ations. One line per observation makes for easier reading. Diagrams are of great value.
The same remarks regarding the detail necessary apply as to the history. There must be a survey of all systems, with par- ticular reference to all those systems actually involved, or likely to be involved, at the same time or at some later stage of the disease. Relevant negative findings are just as important — if not more so — than positive ones in making a diagnosis, and in assessing prognosis and deciding on treatment. So many examples could be quoted that it is simpler to refer the student to any one of his own histories. Ask yourself-
1. Have I recorded all the abnormal findings?
2. Have I recorded as present or absent all the signs which may occur at some stage in this disease?
3. Have I given enough information about each abnormal sign to enable anyone reading this history to assess its significance, and know what importance I attach to it?
4. Have I given adequate information about systems not at present involved, so that if an abnormality is discovered
later it can be correctly interpreted?
Certain specific points may be mentioned under the various systems—
Skin. A note should always be included as the skin may be involved directly (rashes, nutritional changes, jaundice) or indirectly (dehydration) in a number of disorders.
Thyroid. Too often described as either
"not enlarged", or "palpable". The former is ambiguous in the case of male patients particularly, and in the latter case it should have its other features (nodularity, etc.) described.
Heart. The position of the apex beat should be measured. If it is not visible or palpable, then exercise, change of posture, percussion and auscultation may be used as aids. Its position should be expressed as so many inches from the mid-sternal line and related to either the mid-clavicular or anterior axillary lines, the latter being help- ful to a reader of the history who has not seen the patient. Accurate measurement is simply obtained by having a few inch mark- ings made on your stethoscope tubing.
Casual estimations are often inaccurate, and may be misleading when you are trying to observe whether the heart size is diminishing with treatment.
It is useless to elicit a physical sign unless you understand its significance. This point is well exemplified in the case of systolic mur- murs. All the qualities of the murmur should be noted — position, quality, timing, in- tensity, duration, direction of propagation and relation to posture and respiration.
You should then be in a position to appreciate its significance. Many students' histories note "systolic at apex" in the initial examination and never refer to it again.
It is rarely considered in the summary or commentary whether the bruit was as- sociated with organic heart disease, some temporary functional disorder or was a truly innocent murmur. In practice the distinction is of the utmost importance.
Chest. If you are doubtful whether the shape or movement of the chest is asymmet- rical use a tape measure to find out.
Abdomen. Note the presence of surgical scars and examine the hernial orifices. In cases of, for example, congestive cardiac failure, state that the liver is impalpable if this is the case. This indicates more clearly that you understand the significance of liver enlargement in this case than if you merely note "no viscus palpable".
SPECULUM 1964 PAGE FORTY-THREE
C.N.S. The extent of examination of this system varies from case to case. It is how- ever, little extra trouble to test quickly for calf tenderness, position sense, co-ordination and tendo Achillis pain as a routine, and to elicit the cremaster reflexes when the superficial abdominals are in doubt. When recording your findings be careful to indi- cate which is the left and right side.
Additional paragraphs may be required for extremities, locomotor system, etc.
Equivocal signs are of no help in diag- nosis. A physical sign is either present or absent and therefore do not write "? abdom- inal mass". If necessary make a tentative assessment, repeat your examination on a number of occasions, be prepared to change your mind, and thus learn to profit by your mistakes.
Finally, re-read your notes to make sure that they make sense. Remarks such as
"firm prostate tipped", "less moist sounds", and "palpable crepitations" are not im- pressive.
Diagnosis.
Diagnoses are recorded in the following order-
1. Primary condition.
2. Sequelae, in chronological order of development (sometimes requiring subdivision into anatomical and func- tional classes).
3. Associated conditions.
Examples—
a. Rheumatic Heart Disease.
Mitral Stenosis.
Auricular Fibrillation.
Congestive Cardiac Failure.
Pulmonary Infarction.
Malnutrition.
b. Pernicious Anaemia.
Sub-acute Combined Degenerat- ion of the Cord.
Carcinoma of the Stomach.
c. Diabetes Mellitus.
Pyelitis.
Diabetic Acidosis.
Atherosclerosis.
Gangrene of R. great toe.
Always attempt an aetiological diagnosis.
Immediate treatment often depends on the clinical diagnosis; one cannot always afford to await the results of a series of special investigations. Make a provisional diagnosis, and special investigations should then be
designed to confirm or disprove your opin- ion. In practice, the relatives will always expect you to know more than they already do, and will not therefore be impressed if you diagnose the case as "abdominal pain and vomiting". Always consider the likely cause of conditions, such as "anaemia",
"C.C.F.", "C.V.A.", etc., and state your opinion in your provisional diagnosis.
Recently a patient presenting with cough and signs in the chest was confidently diag- nosed in a student's history as "? Lung Pathology". If that is as far as he is pre- pared to venture, subsequent elucidation of the patient's disease is hardly likely to prove him wrong. By making such cautious guesses the student will never be confronted with a mistake and hence will never profit by his experience. All the time spent on a careful history and examination is wasted if the end result is like the following (a recent example)-
? Pulmonary tuberculosis
? Emphysema, ? Chronic bronchitis, pneumonia.
?? Carcinoma of lung.
After a proper history and examination at least one of these should appear the most likely, and they could then have been recorded in order of preference thus—
Provisional Diagnosis — Pulmonary Tuberculosis and Emphysema.
Differential Diagnosis — i. Emphysema and Chronic Bronchitis; ii. Carcinoma of Lung.
If the patient is proved to have tuber- culosis your clinical judgment is vindicated;
if not, retrace your steps and try to see why you reached a wrong conclusion. This does not mean, of course, that you have no right to change your mind in the light of further observation and investigation; in fact a stocktake at intervals is valuable in bringing to light forgotten facts and in piecing all the information together. Incidentally, do not feel obliged to make the same diagnosis as the R.M.O.
Do not make the diagnosis of P.U.O. in a patient on admission. It is rare for some aspect of the history (occupation, contact with infections, etc.) or examination not to suggest one or other disease or group of diseases. Therefore some likely possibilities come to mind. If these initial ideas are proved incorrect, and if no further clue is
PAGE FORTY-FOUR- SPECULUM 1964
afforded with the passage of time, then the fever may be termed of unknown origin.
A provisional diagnosis is necessary in order to decide which investigations should be done first and what measures are to be taken immediately, e.g., treatment, isolation of contacts, disinfection of faeces, etc.
Similar remarks apply to the diagnosis of a main symptom, e.g., Haemoptysis, Jaundice, Haematemesis (in the last-named the surgeon must have a presumptive diagnosis quickly).
Progress Notes.
These constitute a continuous record of the patient's progress in hospital, and their importance lies very largely in effect of pro- gress on prognosis, and very often, on precise diagnosis.
Progress is assessed subjectively and objectively, i.e., how the patient feels, and how you find him. Change in symptom- atology, well-being, sleep, are all matters deserving attention. Objectively, the pro- gress routine examination should cover—
a. The systems affected, with particular reference to the abnormal findings on admission.
Systems which may become affected.
Signs which are of prognostic or diagnostic significance, whether pre- sent or not on admission.
In addition, where a new symptom appears, examination of the relevant system must be undertaken and recorded, with a conclusion as to the cause of the symptom.
The frequency with which findings are recorded will depend largely on the severity and acuteness of the disease, and the rate of progress. All changes should be noted down at the time. Any major change in the Patient's condition may call for a revision of the diagnosis and evaluation of treatment.
The foregoing remarks may seem obvious, but it is all too common to find histories Which contain a detailed account of the initial findings in an ill patient, and a most inadequate account of the progress in hospital. The progress notes frequently consist merely of a series of remarks such as "improved", "less pain", "home soon", With apparently no attempt to interpret the significance of or follow up many of the original findings. Before discharge, check
the original examination and note the final condition of the patient, mentioning what has happened to the abnormal signs in the meantime. This may seem excessive, but at least a number of systolic murmurs, glyco- surias and peculiar blood pressures would be explained.
To take a common example: The patient is admitted with C.C.F. due to mitral stenosis, with all the classical features, together with a systolic murmur at all areas of uncertain significance. The progress notes should record, at appropriate intervals, the level of venous pressure, the size of the liver, condition of the lungs, and the degree of oedema (including perhaps weight); the changes, if any, in the cardiac findings (par- ticularly the position of the apex beat, the nature of the sounds and murmurs); the diuresis produced by digitalis and/or diuretics. If there is pyrexia, note occasion- ally whether the spleen can be felt, petechiae appear, or red cells are found in the urine.
On discharge, when the patient is relatively well, record in particular the information which you would have liked to have had at your disposal when the patient was first admitted, e.g., the position of the apex beat, the precise cardiac findings, not forgetting to record your opinion of the importance of the systolic murmur and whether it is still present. Surgical patients are sometimes discharged with pyrexia without comment.
The treatment given must be included in the progress notes, and the reasons men- tioned for any major change in therapy.
Record the patient's response to treatment, and where it is possible to measure the response, do so (e.g., the amount of urine passed after the use of diuretic, or change in weight).
Special investigations often have a direct bearing on the management of the patient, and therefore a brief summary of these should be included in the progress notes, while detailed reports of X-Rays, Consult- ant's opinions, etc., may be kept on a separate page.
If the above outline is followed, it should be clear to a reader how the patient is pro- gressing, what main lines of treatment and investigation are being followed and what response is occurring to treatment.
b.
c.
SPECULUM 1964 PAGE FORTY-FIVE