CLINICAL HISTORIES If a patient is seriously ill, the trained nurse will keep records of the case after the physician has taken the history of the patient's immediate past and the story of the invasion of the present disease. In hospitals this is done by the medical interne, and elaborated by the attendant. Unfortunately, many physicians are very careless in not taking and carefully following histories of the patients who come to their office for treatment. For medical success good history taking is absolutely essential. It is not necessary to ascertain the family tendencies, or whether the individual had mumps as a child, if he comes to the office for a sore throat or a tonsillitis. It is, however, absolutely essential to investigate the whole history of the case, if the patient comes with some chronic systemic condition. It is not necessary for each physician to have the same plan or arrangement for his history taking, provided he follows out constantly his own method; it is unimportant whether he gets the general history of the patient's previous condition first, or the history of the present condition first. A working plan is to obtain the name, age, sex, condition (married or single), occupation, complaint in all its details, duration, history of previous diseases, and a brief family history. Then begins the examination of the patient. First, the verbal examination, which should be more or less brief, or more or less in careful detail, depending upon the complaint of the patient: (1) a detail of the exact occupation and life; (2) the diet, especially the amount of tea and coffee and meat taken, and whether there is a craving for any particular article of food, or whether much sugar is eaten; (3) as to appetite, flatulence, pyrosis, nausea, vomiting, abdominal pain, and the activity of the bowels; (4) the ability to sleep, and whether or not the patient rises to urinate, and the number of times; (5) the ordinary daily frequency of urination, and any disturbance of that function evident to the patient; (6) the occurrence of pain, not previously mentioned by the patient, as headache, or joint or muscle pains; (7) whether or not there is palpitation, dyspnea on exertion, or bleeding from any part; and (8) whether or not there is cough, and the character of the cough and expectoration. If there are headaches, the character of the headache should be ascertained, and a careful study of the relation of the use of the eyes to the headaches should be made. In women, abnormalities of the menstrual function should be noted, and the number of children born and the number of miscarriages, if any, should be recorded. Next, there should be a discussion of the tobacco habit, and of an alcohol or any drug habit; and the frequency of taking drugs of any kind should be ascertained. The second part of the examination is physical, and should begin with inspection as to the color and texture of the skin; as to the general nutrition; as to abnormalities. Next there should be inspection of the tongue, throat, tonsils, teeth, and gums; the ordinary reflexes should be tested; and the pulse and temperature taken. The examination proceeds with a careful study of the heart with the patient sitting, standing, and lying down; and the blood-pressure is taken. Examination of the lungs is by inspection, percussion, and auscultation, and by any other method deemed necessary. A careful examination of the abdomen with the patient both standing, and lying down must be made, and finally the urine must be tested. The above examinations are essential in every case that is to be properly treated, unless the condition is an acute, simple, self-evident disease. Special examinations need not be outlined. One patient requires an examination of the twenty-four hour urine, another a kidney test, another a differential blood count, another an examination of the sputum, another requires a culture made from some excretion, another a careful eye examination, another an ear examination, another an x-ray picture, and another a pelvic examination. Pelvic examinations should be much more frequently made, both in males and females. The treatment is then outlined and carefully recorded, and the history card filed, ready for use on subsequent visits. A criticism of previous decisions and of the treatment given should follow on the card, at each date that the patient is again seen, and many times a careful review of the whole history just before the patient returns will enable the physician to give him is the following therapeutic chart: patient which the physician can give. examination should not be made, means the best care of a the consideration of whether or not some other technical the best advice possible. Self criticism by the physician, and Suggestive for the treatment and management of a patient Copyright reserved by Americal Journal of the Medical Sciences, Lea & Febiger, 1916. THE HYPODERMIC CASE The hypodermic case should contain tablets of: Apomorphine hydrochloride each 10 grain. Morphine sulphate each grain. Scopolamine hydrochloride each 200 grain. Strophanthin each 500 grain. THE POCKET MEDICINE CASE The pocket medicine case should contain for dispensing (in small numbers) the following tablets: Morphine sulphate... Strychnine sulphate. Nitroglycerin. Atropine sulphate.. Quinine sulphate. Acetanilid (1 grain) with sodium bicarbonate (3 grains). Ko grain 30 grain 200 grain 500 grain 150 grain 5 grains Calomel (1⁄2 grain) with sodium bicarbonate (1 grain). Aloin... Powdered ipecac. Strychnine sulphate. Extract of belladonna. 0.006 Gm. (0 grain) The doses of some of the above tablets are small, but more than one tablet may be given at a time, if needed. The small dose of atropine allows a tablet to be given every one or two hours, for a time, for colds. The quinine tablet is for use as a placebo, when some treatment is necessary though medication is not needed. THE ALWAYS-READY HANDBAG Preparedness in every respect is essential to render any service, and is an absolute necessity for the physician to render service in emergencies. Preparedness may mean saving of life, and always means saving of valuable time, both for the patient and for the physician. The physician's handbag should contain not only everything needed to meet an emergency, but many things that are needful in making a diagnosis. It should not be necessary for the physician to make another visit in order to take a throat culture; to take a blood smear for a malarial fever or typhoid test; to take blood for a blood count; to take blood for a Wassermanu test; to do venesection; to do spinal puncture; or even to give a transfusion of physiologic saline solution. The small equipment necessary to do these things should be in the handbag. The bag should also contain male and female catheters, sterile lubricant oil, and a small test case for urine. It should also contain a pocket instrument case, gauze bandages, adhesive tape, bichloride of mercury tablets, tincture of iodine, a small can of ether, a bottle of chloroform and a chloroform inhaler, and cocaine and novocaine tablets. It should also contain a stomach tube complete with funnel, tongue depressors, a piece of solid rubber for placing between the teeth to keep the jaws apart, copper sulphate powders each containing 0.50 Gm., and powders containing zinc sulphate 1 Gm. and powdered ipecac Gm. for use as emetics. As milder emetics a small can of mustard and a bottle of syrup of ipecac for young children may be carried. A small bottle of tannic acid and a brief list of poisons and their antidotes completes this equipment. The bag should also contain the following preparations for hypodermic administration: Caffeine sodio-benzoate tablets, each 3 grains; ampules of ergot; ampules of strophanthin (120 grain); ampules of post-pituitary solution (1-10,000); ampules of epinephrine (1-10,000); ampules of camphor in oil; and ampules of digitalis. It is now possible to obtain individual sterile hypodermic units (each consisting of a needle and a collapsible tube containing the medicament), the Greeley patent, of most drugs used hypodermatically. Several of these containing such drugs as morphine, strychnine, atropine, and apomorphine may well be carried in the bag. The bag is made complete with a small alcohol lamp, containing solidified alcohol, and a small cup or spoon for sterilizing water. |