VII.Practising Medicine – Case History

Dear future doctors!

As quite soon you are going to practise medicine in our clinic (the probability that some of you have already had such an experience is quite high), we would like to stress some extremely important points to you… With the modern trend toward objective and laboratory methods of diagnosis (don’t suppose we consider them to be unreliable ones), you mustn’t decrease attention to the patient’s story of his troubles and problems. A careful history always leads to making a correct diagnosis. It gives the information which aids the doctor in choosing the type of recommended therapy or surgery. The physician who is able to gain the patient’s confidence will find the problem of physical examination greatly simplified. This is particularly true of children…We hope you’ll manage to cope with the most important document in medical practice – Case History or Case Report, or Medical Record, or Clinical History. To make the task more complicated we suggest filling in the form with the data taken from the dialogues given further. A short block of useful information after each recorded conversation should be thoroughly translated in written form:

Surname First names

Age Sex Marital status

Occupation

Present complaints

O|E General condition ENT RS CVS GIS GUS CNS

Immediate past history

Points of note

Investigations

Diagnosis

Dialogue 1

- Doctor, help my boy! He throws up the food he takes. In the morning he had convulsions and nearly passed out. I’m so afraid he won’t live the day out, unless you help him, Doctor.

- Has he a fever?

- I don’t think he has. Jimmy’s body is rather cold.

- Well, we’ll see… It must be something he has eaten. He may have eaten some food that was spoiled and disagreed with him. What food did he take for supper yesterday and breakfast today?

- He had a tin of sardines for breakfast. Our little boy likes them without any bread. You know, my husband and I didn’t taste them.

- Has he ever had any trouble with his bowels? Constipation or loose bowel movement, for instance?

- He has never complained of it. His bowels seem to be all right.

- Well, I suppose it’s better to do him a stomach washing.

Over to you (1)

The commonest cause of vomiting is faulty feeding, i.e. the child who is very hungry swallows too rapidly and a lot of air is swallowed with the meal. There are many other reasons why a baby may vomit, such as infection. This may involve the gastrointestinal system or may involve any other part of the body, e.g. earache, and throat infection when the child vomits with a bout of coughing. Some children are more prone to vomiting than others. Another serious cause of vomiting is obstructive lesion in the gastrointestinal tract, which could be serious indeed.

Dialogue 2

- Doctor, the little girl, Rosa Stevens in Room A, first floor, has convulsions.

- Don’t be in fear. She has convulsions because of a high fever and three day’s constipation. Make her take these tablets every two hours, nurse.

- Shall we send her home today? Her mother is waiting for the answer. She is on the anxious seat, poor thing.

- Please, tell her that the girl should stay here over night and perhaps we’ll decide the problem tomorrow. Don’t you think so? If not, give me a piece of your mind, what you’re thinking about it.

- Yes, of course, I completely agree with you. She is too young, only 2, to be treated at home. To be on the safe side it’s better to have the girl here.

Over to you (2)

Constipation is a relative term. A baby may not pass stool for two days but at the end of this period he may pass a soft stool. If he passes hard stool then you can label it as constipation. The commonest cause of constipation is inadequate food, roughage or carbohydrate. If an older infant has constipation his food intake should be increased, i.e. early supplementation with vegetable soups, mashed vegetables etc. should be started. In older children increased roughage and water is required, vs. raw vegetables and fruit.

Dialogue 3

- Doctor, help my Bobby, please!

- What’s the matter with him?

- When I came home I found my little boy crying bitter tears. I couldn’t stop him crying. I saw at once that there was something wrong with his left ear.

- Why did you think so?

- He tried to pick his left ear with his finger and when I wanted to have a look at his ear, he pushed my hand away.

- Didn’t you ask him why he was crying?

- Certainly I did ask him but he wouldn’t tell me. There were other kids playing and I saw them trying to insert some small objects in each other’s ears.

- Well, they often do it out of mischief and get into trouble… Never try to remove any object out of the ear. It’s easy to push it deeper and more trouble may occur. Nurse, get everything ready. I’ll examine the boy’s ear.

Over to you (3)

Solid objects, such as beans, peas, buttons, or small seeds are often introduced into the ears by children. Such things as seeds absorb moisture and swell, making their removal difficult. Do not use pins or pieces of wire to try to dislodge those, as there is great danger of seriously injuring the ears. Insects, such as flies or bugs, frequently crawl into the ear. They can be killed and the buzzing stopped by dropping a little olive oil or mineral oil into the ear. In every case, the object should be removed by a physician.

Dialogue 4

- How old was the child you admitted a couple of days ago?

- She was a 2-month-old girl, colleague.

- What problem made her mother bring the baby to the clinic?

- She had been noted to become jaundiced, and when I examined her I found the baby was anemic too.

- Were lab values significant?

- Oh, yes. The values of hemoglobin and cholesterol were remarkable.

- Didn’t you notice any lymph nodes enlargement?

- No, I didn’t.

- What was the course of the disease?

- Jaundice was progressively getting worse.

- What pathologic signs and symptoms accompanied it?

- The liver was slightly enlarged and the spleen was one finger below the left costal margin.

- What should be done first, you think?

- Bone marrow aspiration to exclude acute leukemia.

- And won’t you do blood culture? She may have an underlying infection to explain anemia.

- To begin with I think that blood should be transfused because of the low hemoglobin. You see, I don’t like the way she is doing. We constantly keep an eye on her.

- Well, it would be better to discuss the problem with the visiting pediatrician, Professor Figner. Today he is making the round… Look, he is coming here.

Over to you (4)

A new-born baby is born with a large amount of red blood cells in the body. Since the requirement of oxygen in the uterus is more and the child has to depend on the mother’s circulation for oxygen, a large number of red blood cells in the fetus are required to carry oxygen. Once the baby is born, this large amount of red blood cells is not required. They undergo destruction. The pigment thus released is normally transformed in the liver and is excreted, but since there is a large amount and also the liver of the baby is immature and hence not able to cope with the total pigment, jaundice is produced. The other causes of jaundice can be infectious and certain congenital conditions which may be operative during pregnancy.

Dialogue 5

- On admission to our hospital my patient, a 5-year-old boy, had a bad headache, malaise, and backache, a sore throat, marked loss of appetite, a rash on the face and trunk, and a temperature of 38ºC.

- What kind of rash was it?

- It was a vesicular rash. The rash appeared more numerous on the second day after the admission and completely involved the entire body surface.

- What else did you notice?

- I noticed that the rash evolved through the typical stages of chickenpox. The skin lesions of chickenpox in various stages were present over the scalp, face, trunk, with lesions over the limbs. The patient appeared quite ill, his pulse was 100 beats per minute, but there was no cyanosis.

- Did he complain of anything?

- Yes, he did. He complained of cough and chest pain.

- Did you examine his lungs and his heart?

- Certainly. There were moist rales with coarse breath sounds in both lungs; chest X-ray findings were those of pneumonia.

- And what else aggravated his condition?

- His chest pain. He complained of left anterior chest pain. The heart sounds were strong and no rub or gallop rhythm was present.

- What diagnosis do you suggest?

- I believed first it was chickenpox with pneumonia, but he again complained of steady left anterior chest pain. I examined his heart most thoroughly and noticed that a pericardial rub was evident. So he had pericarditis too.

Over to you (5)

A single skin lesion can be regular or irregular in shape. When there are many (multiple) lesions, especially macules or papules, the result is a rash (or spots), for example the rash of an infectious disease such as rubella. A rash is said to erupt or break out.