It. J. Med. $c.

June, 1964, pp. 271-282

Printed in the Republic of Ireland

MEDICAL RECORDS, PATIENT CARE, AND MEDICAL

EDUCATION

'By LAWRENCEL. WEED, M.D.,

Department of Microbiology, Western Reserve School of Medicine,
Cleveland, Ohio.

M IJCH has been written in general terms about medicine as a

science and the doctor as a scientist. Very little is done in
specific terms to audit physicians or medical institutions on a
routine basis to determine just how scientific medical practice on all the
patients really is. An audit by an outside authority will not threaten
those institutions where medical care and medical education are
approached with scientific discipline, and where intelligible hospital
records are produced which not only prove adequate care, but which
contribute to it. By the same token, an audit can and should draw
attention to those institutions where records are " ink splashes " and
" private scribbling ", and where conferences, research laboratories and
hierarchies of medical ~lite tend to obscure the haphazard and careless
recording of the daily clinical data upon which all medical care, medical
education, and much clinical investigation depend.
An audit requires that the data be kept in a consistent and organised
fashion. What follows is a plan Whereby the hospital record, particu-
larly the progress notes, can be made the central point in medical care
and medical education. It is proposed that conferences and rounds
should not be allowed to take place until all the records have reached
certain standards of uniformity and completeness. It is not that con-
ferences are of secondary importance to the physician; rather it is that
practical or theoretical knowledge is important to the physician only as
he understands it and relates it to the details of the problems that
confront him. There is nothing wrong with the philosophy that what
you do with your patients in a practical way should have relationship
to what you know about your patient's problem in a theoretical way.
When such integration is not possible because the experimental approach
and the data collecting process on the patient's problems are too sloppy
and disorganised, then the display of unrelated erudition at the con-
ference level or on rounds is pointless if not immoral.
The rules that follow may appear obvious, even trite, but poor patient
care and poor medical education are more often the result of ignoring
simple and obvious matters of order and discipline, than they are due
to lack of a specific curriculum or sophisticated specialised knowledge.

There are those who will resist the proposition that medical
records should hold the central position in patient care and the
teaching of clinical medicine. There are physicians even in univer-
sity hospitals who defend their right to carelessness in their records
271
 272 IRISH JOURNAL OF MEDICAL SCIENCE

because they do not believe them to be a true reflection of the

quality of a physician's care. 4f there is no adequate record of
what a doctor does and what he fails to do, how can one judge the
quality of the care he provides? There are residents and staff-men
who maintain that the content of their records is their own business.
I n reality, however, it is the patient's business and the business of
those who, in the future, will have to depend on that record for the
patient's care, or for medical research. There are physicians who
say they do not have the time for records. 'They should be reminded
that a scientist doesn't read his data on one day and put it in the
notebook the next day, or next month; if he did, he would waste
more time than he saves. Furthermore, the time spent at con-
ferences on other people's data should never be at the expense of
the data on the physicians' own patients. I n summary, no one
should have the freedom to be disorganised and incomplete in the
collection of data and thereby bury it forever. Freedom should be
at the level of interpretation; even there, reasoning should be re-
corded and an audit not only should be expected but welcomed as
insurance for the patient and education for the physician.

Rule 1 - - T h e present illness should be a statement of the relevant

facts about a problem or series of problems. Each problem should be
discussed separately. All the available information concerning a given
problem should be presented, whether it came f r o m the patient, a rela-
tive, a friend, an old chart, a laboratory data book, a pathology slide
cabinet, or the files in an x-ray department. I f a statement is believed
to be of doubtful reliability it should be so stated or the statement
omitted. When the story is long and the data voluminous, a table or
a graph should be constructed. The graph or table should be so
organised that the data collected during the hospital stay or following
it, can be added at the time the d ~ a ar~ acquired. I n chronic disease
particularly, the hospital stay should not be treated as an isolated
incident, but rather as an opportunity to get, u n d e r more controlled
conditions, a few more points on already established curves.
Enslavement to the conventional format of the medical history can
make a problem almost incomprehensible by separating the pertinent
facts, putting some in the past history, some u n d e r laboratory data and
some in the systems revie.w. (See Appendix : Case I, p a r t B.)
One example may serve to illustrate. I f an intern, writing up the
present illness of a 65-year old man with intestinal obstruction who is
about to undergo surgery, fails to include in that present illness a
separate paragraph dealing with the cardio-pulmonary and renal situa-
tion in which he mobilises every last bit of historical, physical and
laboratory data about those two systems into a meaningful statement of
the current status, then he obviously does not realise that patients are
lost in surgery as often because of failure to assess the heart and kid-
neys, as for any more specia]ised surgical reason. The intern who in
this sense does not look at the problem as a whole, fails to realise that
all the fluid balance he tries to manipulate himself, is in reality, mediated
by his patient's heart and kidneys; when they are poor, the intern needs
 MEDICAL RECORDS, PATIENT CARE, AND MEDICAL EDUCATION 273

all the help he can get from experienced people before the disasters
happen and not after; when the cardiac and renal systems are good, he
can do unbelievable violence to principles without even knowing it.
Medical education and patient care are not served by merely saying
these are matters for the anaesthetist and the consultant.

The student's way of organising the data should reveal to the

teacher whether or not the student writing the history sees the
whole story. As the student builds, we should be interested to see
not only that he piles all the bricks, 'but also ~vhere he piles them,
in what pattern and how this develops the architecture of his
thoughts. This is exactly why we cannot t ry short-cuts such as
printed forms for histories and physical examinations. The student
must go through the labour of organising his thoughts. This is the
essence of his development. The teacher must go through the
labour of seeing that he does it. A doctor may have to rewrite a
record, not to change the facts, but to organise them so someone
else can understand them. The outstanding defect of the records
presented in the appendix is that they were not rewritten. The
record is a communication for all time, not just a sheet to clear the
intern the next morning, or a ticket to get a doctor by a record
committee.

Rule 2 - - A list of impressions should be made which includes every

problem in the patient's history, past or present. The impression should
be an up-to-date table of contents of any chart. The problems that are
changing the most rapidly and which are on the steepest downhill curve
should appear first in this list. Each problem should be stated as it
exists at the time. For example, if abdominal pain is u n e x p l a i n e d -
" abdominal pain " - - s houl d be the impression--not a list of diagnostic
guesses which only reflect the experience, or lack of experience and the
prejudices of a given person. No problem, however insignificant or
minor it seems at the time, should be omitted. No one can be certain
on admission which problems are progressing and which ones in the
long run may prove the most significant if left unchecked. An un-
explained eye symptom found only in a systems review may be over-
looked--a clear statement of the same problem in a numbered impression
followed by an intelligent progress note (see below) may check the
glaucoma in time.
When an impression is elucidated or changed, it should be annotated
clearly on the original list, giving either a new impression, or identifying
by date the progress note which explains the current situation. If a
new problem develops after admission, a new impression should be
added to the original list and dated accordingly.

A student should not hesitate to record impressions in terms of

symptoms or physiology so that he does not put his mind in a
diagnostic straight jacket. Too many waste time trying to confirm
the diagnosis they committed themselves to in the first ten minutes.
A doctor's first function is to collect data and to keep them in order.
Often the diagnosis will make itself known as a natural sequel.
 274 IRISH JOURNAL OF MEDICAL SCIENCE

A n y doctor who takes pride in off-the-cuff diagnoses may be right

at times, ,but he is keeping a chart on himself, not the patient. The
joy he feels when he is right is nothing compared to the misleading
chain of events he sets into motion when he is ,wrong. Hours that
might have made a significant difference can be lost, for example,
when a patient with a reversible metabolic crisis is left unattended
with the diagnosis of a " CVA ". Time is not saved and the true
value of necessary emergency action is not enhanced by writing
premature, speculative diagnoses which the data available at the
time simply cannot support. It is recognised that in most instances,
impressions mere written as working hypotheses, but experience has
sho~vn that in busy clinics, busy practices and busy wards, people
who have neither the time nor the discipline to examine the original
evidence are repeatedly diverted from vigorous diagnostic or thera-
peutic action by placing unwarranted finality in a misleading initial
impression that never really needed to be written in the first place.
No system should encourage jumping to early diagnostic conclusions.
Instead, the " gradualness " that Pavlov recommended to his
students should be the deliberate and proper state of mind for the
evolution of a difficult idea.

Rule 3--~A plan and the diagnostic and therapeutic orders involved
in the plan should follow the impression. Each problem should have its
own plan whose number corresponds to the appropriate impression so
that an experienced observer can see at a glance whether an anaemia,
or a urinary tract infection, for example, has a complete and reasonable
plan. Too many serious o~nissions occur when sleeping pills, BUN
orders and side rails are all mixed up in a list of twenty items which
were spun off the top of one's head in a totally random fashion.

Rule 4 Each progress note should relate directly to the list of im-
pressions. Each paragraph should be preceded by the .number of the
appropriate impression. This immediately tells the reader whether the
progress of the anaemia, or the urinary tract infection, etc., is the subject
under discussion. I f a new problem is being discussed, a new impres-
sion should have been added to the original list and dated accordingly.
No progress note should be written without recognition paid to previous
progress notes on the same problem. People should not disagree with-
out explanations; charts should not be weighted down with inconsis-
tencies without any effort to recognise, remove, or explain them.

Progress notes should be up-to-date and intelligible. One is

sceptical about the pressures of practice making impossible a
thorough, systematic approach. In all areas of human endeavour,
thoroughness, form and a research attitude save time and money
and health for all concerned. Who has not seen the patient in pul-
monary edema in the middle of the night requiring the time of
many people because on an admission six months before for an
elective operation, no impression of the beginning cardiac symptoms
was written, no plan organised, and no progress notes ever recorded ?
To be intelligible is to be " found out " and to be " found out "
 MEDICAL RECORDS, PATIENT CARE, AND MEDICAL EDUCATION 275

is the first step in education. To the degree doctors restrict their

art to themselves alone by keeping unintelligible records they may
be denying the patients scientific light on their problems. Indian
medicine men and ancient Egyptian priests used to guard their
secrets to keep uninformed and fearful patients in their grip. The
neglect of a record that will tell everyone exactly what was done
is a form of secrecy and secrecy has no place in the science of
medical practice.

Rule 5--Graphs and tables containing all the " moving parameters "
shodld be kept on all problems where the data and time relationships
are complex. The frequency of record-keeping, or data collecting de-
perids upon how " steep is the curve ". A chart of a rapidly changing
bmm patient might have recordings every hour whereas a chart on a
patient with cirrhosis and persistent ascites might have recordings once
a week, or once a month; whatever the frequency, the configuration of
the patient's course can be detected at a glance '(Appendix Case 2.)

There are times when data are sufficiently complex that only the
most foolish will try to arrive at conclusions on work rounds with
data scattered over laboratory sheets, progress notes, papers in one's
pocket, telephone conversations with the professor, and idle ques-
tions from students and nurses. It is well orga~dsed data kept every
day by a student on his own patients, not conferences, that protect
his mind from imprisonment by the concepts of others. The data
kept by the physician on his own patients provide the most effective
immunization he will ever have against the deadly plague of general
statements made at conferenves and the prejudices and limitations
of those who teach him. Without these biological realities in the
data before him, the student will take anything you tell him and
will carry to community medicine the fixed mind that ignores
records and forgets how to read about a problem he thought was
solved long ago.
Any professor or practitioner who neglects to teach and practice
the discipline of collecting data, in favour of a variety of pursuits
which yield more prestige, may endanger the patients entrusted to
his care. Any teacher who does not help his student to develop a
disciplined approach, is doing the student a grave injustice and is
depriving him of the exhilarating intellectual experience and stimu-
lation of finding out for himself. We all recognise the humanitarian
considerations that should stimulate and primarily motivate the
physician, but they alone do not automatically insure the disciplined
approach that good care requires. Nothing is better calculated to
turn the patient's hope into despair and his confidence into frustra-
tion than to confront him with a sympathetic, but intellectually
undisciplined physician whose warm-hearted beginning somehow
gets forgotten in the disorganisation and confusion that slowly
unfold.

The question arises as to whether the record, as the central point of

operation in a teaching system, does not have many pitfalls. Cannot
276 IRISH JOURNAL OF MEDICAL SCIENCE

the record be falsified in a most plausible manner? People unintelligent

enough to be dishonest in scientific matters are not usually bright
enough to falsify the record within the framework of biological reality.
Detailed scrutiny of any record, including nurses' notes and orders, will
invariably betray those who are careless with the truth. To bring
accuracy, uniformity, precision and completeness to medical records is
a well defined task that can be accomplished provided the need is recog-
nised. ,Many have been too preoccupied to serutinise truly a record and
too weak in leadership to demand its improvement. Others, though they
are dedicated and hard working, have centred their efforts elsewhere and
have tried to convince themselves that all the records are not as impor-
tant as that. Accordingly, we have neglected the complete care of many
patients and the full development of many students.
Medical schools should not underestimate the damage they have done
to their own institutions and to the communities served by the doctors
they have trained, by sending out physicians with the sloppy house-
keeping ha~bits that their medical schools have degenerated into in their
outpatient departments, their general medical wards, their private ser-
vices and their emergency rooms. Leaders in medical schools act as if
community medicine were somebody else's problem, when in reality it is
solely in the hands of their own graduates. Clinical professors do have
a major responsibility to research and the advancement of medical
knowledge, but to paraphrase William Letwin, " as men can be short-
sighted, so too can they be excessively long-sighted " ; they can cheat the
present, as easily as they can cheat the future and in that sense the
production of medical students and house officers undisciplined in medi-
cal practice cannot be excused by the development of highly specialised
surgical techniques, or by advances in ~nolecuIar biology.
Nor in discussing these problems of clinical teaching should basic
science teachers go without blame. Basic science professors who rightly
hold a graduate student to every detail in a scientific article under dis-
cussion, or in the performance of his research, somehow in the interests
of " coverage " turn out undisciplined hordes when it comes to medical
students. Basic science professors and their graduate students have a
guaranteed audit, because they must eventually publish the fruits of
their daily work in order to survive and this involves editorial review
by outside observers._ The charts of patients are not published and
medical students therefore need to leave their basic science training with
a highly developed sense of self-discipline. The manner in which some
laboratories and lectures are handled with a " cook book " and a syllabus
to memorise does not develop this capacity for self-discipline in the
organisation of a problem and the collection of the data involved. It
must be remembered that the very students ~hom basic science professors
launched into the field of medicine, are the ones who a mere four or
five years later are keeping charts that do not even suggest the scientific
recording of data. It is no excuse to say that the problems are different,
the emergencies greater and the patient cannot wait. Indeed the greater
the emergency and the more complex the problem and the more multiple
the variables, the greater the discipline needs to be. There must be
something wrong when a study vn a biological problem involving E coli,
 MEDICAL REGORDS, PATIENT CARE, AND MEDICAL EDUCATION 277

or a methyl group of thymine is better planned, better recorded, better

analysed and better audited by experts from other institutions than a
study on a biological problem involving human beings in which an
element above and beyond the science required is also present.
Medical schools should hold their graduates responsible for their
medical records no matter where they may be. Indeed if they were to
survey the performance of their graduates through their records they
would help community hospitals with their standards and would begin
to get some feed-back on all the medical education programmes under-
way. In addition, records on a large scale would become available for
computer analysis.
The teaching of medicine and the practice of medicine are a public
trust. The records of medical practice should be audited to ensure at
all times that the public is always served and never exploited. The
medical schools should set the standards for medical records in the
example they provide and the principles they teach. Scientific training
not only does not detract from humanitarian behaviour, but it may at
times be necessary to implement it. Doctors should be trained as
scientists and should be subjected to all the intellectual discipline de-
manded of good scientists. As physicians, they should not, in the name
of medical ethics, bc allowed the preposterous position that they have
the right to set their own standards, keep records as they please and
audit themselves.

APPENDIX

CASE ]
PART A . - - T h i s record w a s k e p t b y a p h y s i c i a n w h o w a s a g r a d u a t e o f a g r a d e A
m e d i c a l school, h a d m a n y y e a r s o f e x p e r i e n c e a n d w a s h i g h l y s u c c e s s f u l in h i s practice.
PART B . - - T h i s record is o n t h e s a m e p a t i e n t d e s c r i b e d in P a r t A, w h o w a s a d m i t t e d
e i g h t m o n t h s l a t e r u n d e r t h e care o f a different p h y s i c i a n w h o h a d less p o s t - g r a d u a t e
e x p e r i e n c e . P a r t B i l l u s t r a t e s m a n y o f t h e " r u l e s " o u t l i n e d earlier. W h e t h e r t h i s record
r e p r e s e n t s t h e o p t i m u m care is n o t t h e q u e s t i o n , b u t it d o e s m a k e possible a decision
a s to t h e g e n e r a l q u a l i t y o f p a t i e n t care. T h e a d e q u a c y is i m m e d i a t e l y a p p a r e n t in
c e r t a i n areas, as is t h e i n a d e q u a c y a n d u n r e s o l v e d s t a t u s in o t h e r s , a s in t h e case o f t h e
i m p r e s s i o n o f h y p e r p a r a t h y r o i d i s m . T h r o u g h r e c o r d s s u c h as t h i s one c a n a s s e s s t h e
p h y s i c i a n ' s s e n s e o f discipline a n d h i s p r o g r e s s in s e l f - e d u c a t i o n t h r o u g h t h e collection
a n d s t u d y o f d a t a o n biological p r o b l e m s .
N e i t h e r p h y s i c i a n k n e w b e f o r e h a n d t h a t e i t h e r r e c o r d w o u l d a t s o m e f u t u r e d a t e be
reviewed. R e c o r d s s i m i l a r to t h e s e are n o t l i m i t e d to a n y locality or t y p e o f m e d i c a l
institution, but have been observed at many university and community hospitals.

PART A

Chief Complaint : R e c u r r e n t c y s t i t i s . P a i n in u p p e r a n d lower back.

Present illness : P a t i e n t h a s h a d cold r e c u r r i n g for 6 weeks. C o m p l a i n s o f p a i n in
b a c k o f n e c k a n d chest, also a c r o s s lower back. Since d e a t h o f h u s b a n d (accidental) in
spring, s h e h a s b e e n ill a t e a s e a n d d e p r e s s e d .
Past History : T h y r o i d e e t o m y 10 y e a r s ago. H a s h a d t u b a l p r e g n a n c y , b i l a t e r a l
salpingectomy, cholecystectomy.
F a m i l y History : H u s b a n d d i e d o f a c c i d e n t a l d r o w n i n g - - 3 c h i l d r e n l i v i n g a n d well.
Physical Findings (as recorded in full) : N o s e a n d t h r o a t n e g a t i v e . H a s s o m e h o a r s e -
n e s s . Chest : N o r a l e s h e a r d t h o u g h c o u g h s f r e q u e n t l y . H e a r t s o u n d s n o r m a l a n d regular.
N o m u r m u r s . Abdomen : G a l l b l a d d e r - m i d l i n e scar. T h y r o i d scar. Pelvic and Rectal :
278 IRISH JOURNAL OF MEDICAL SCIENCE

Negative. Extremities : Scar above knee where cyst was removed. On arm an area
of ecchymosis, apparently from striking same.
Working Diagnosis : (1) Neurosis. (2) Cystitis. (3) Backache, cause undetermined.
(Attending) (Signed)

No Progress Notes.
Discharge Summary.
Condition on Discharge : Improved.
Final Diagnosis : Anxiety neurosis.
Discharge Summary : P a t i e n t has complained of backache, general pains and recurrent
cystitis since sudden accidental death of husband in June. Brought to hospital for
x-rays o f back and bladder examination. Seen by orthopedic and urologic surgeons
whose notes are enclosed. No organic difficulty found. Discharged on tranquillizer to
be followed in off• While in hospital had blurring vision, right eye--ophthalmic
consult on chart.
(Attending) (Signed)

PART B

This 57 year old widow is a d m i t t e d because of nausea, vomiting and malaise over
the p a s t two days. There has been frequency of urination for several weeks (see below).
She denies fever or chills. Yesterday and today had moderate headache, better tonight.
Nausea relieved with 50 mg. Dramamine this evening. No vertigo or dizziness.

Associated problems
1. Hypothyroidism : Subtotal thyroidectomy 14 years ago with tissue
diagnosis of Hashimoto's disease. She has had some hoarseness since.
Seven years ago she developed weakness and easy fatigue, cholesterol
was 375 mg.% and RMR - 3 5 . She was described as being a typical
myxoedema patient. Was started on thyroid 1 / 4 grain t.i.d. Patient
states this dosage has not been changed. She has not taken it regularly.
BMR f o u r years ago was - 2 0 , none apparently since then. No P.B.I.
She still has constipation, lethargy, d r y coarse skin, aches in arms and
shoulders and leg cramps.

2. Peptic ulcer--Hiatus hernia: Since approximately 15 years ago,

she has had recurrent u p p e r abdominal distress. H e r gallbladder was
removed at age 30. Hiatus hernia was demonstrated here ten and two
years ago. However, on last two G.I. series two years ago and nearly
a year ago, hiatus hernia not detected. I t was small before. However,
a pyloric or pre-pyloric ulcer was first detected two years ago. This
was much smaller (initially 8 mm.) a year ago. She has had u p p e r
abdominal pain only once or twice during the past month. A t times,
however, it awakens her. There has been no abdominal pain with the
present vomiting. A stool was 3 +, seven years ago, no stool studies on
subsequent admissions. Patient describes stools as dark, not tarry. No
history of haematemesis. Does not drink. Has taken Amphojel irregu-
larly and Belladonna ten drops t.i.d., has not elevated head of bed. Does
not follow Bland Diet. Has never had haemoglobin below 12 gms. on
five admissions in the past eight years.

3. ? Urinary tract trouble : Seen by urologist two years ago because

of frequency of urination and supra-pubic pressure. Cystoscopy done
 MEDICAL RECORDS~ PATIENT CARE, AND MEDICAL EDUCATION 279

twice then and I V P's were normal. Urine was free of albumin, sugar
and showed 20-30 WBC on voided specimen. Culture showed few
Staphylococcus albus only. Past month frequency stated to be about
every 15 minutes but only l x nocturia and denies dysuria. No history
of vaginal bleeding. No P A P smears have been done. NPN 31 mg.%
three years ago. Presently (to-night) patient not having frequency.

4. ? of blood dyscrasia: Clotting time of 12, 18 and 18 minutes two

years ago. Platelet count was 286,000. Presently tourniquet test shows
15-20/2x2 cm. area--there were scattered ecchymotic areas on the fore-
arms. She states these have been occurring for several years, usually
with slight trauma. 'Other than 3 + stool seven years ago, no other
evidence of bleeding, save retinal abnormality discussed by two ophthal-
mologists two years ago on chart which has cleared. She does not take
vitamins and eats little meat.

5. ? Hyperpar~thyroidism : ,Ca of 11.5 mg.% recorded in chart three

years ago. Not repeated. Patient does complain of leg cramps, numb-
ness in extremities and occasional spasm of digits. However, Trousseau
was negative this evening.

Past History : M I ) ' s - - H i s t o r y of rheumatic fever at age 13 with swollen joints and
heart murmur. Heart size has been normal by repeated chest x-rays over past few
years and ECG normal 10 years ago.
Operations : Appendectomy ~t age 11. G.B.--age 30. Tubal pregnancy and ligation
approximately at age 35. Subtotal thyroidectomy at approximately age 46. Meno-
p a u s e - a g e 49-59, Gravida 5, para 4, abortion, I. Medications : Occasionally thyroid,
Belladonna, Amphojel.
Family History : Mother died at age 75 during G.B. operation. Father died. One
brother died of bleeding ulcers, one brother died of concussion. Two sisters and two
brothers living and well. Husband drowned last year, worked for an electric company.
Social History : Lives in town, does not smoke or drink. Husband drowned last
Summer, moderately depressed since then although denies crying spells. Recently
staying with daughter at camp. Has 4 children living and well. Two brothers work here
in town, one is cook in hospital.
Review of Systems and Physical Examination carried out in traditional fashion with
full notes.
Impressions :
1. Myxoedema. 5. Bleeding tendency, possible
2. Pylorie ulcer, ? active. vitamin deficiency.
3. Urinary frequency, R/O active 6. Exclude hyperparathyroidism.
disease. 7. Exclude angina pectoris.
4. Subacute respiratory--G.I, ill- 8. Class IV. Pap. of cervix.
ness--uncertain aetiology. (See notes Aug. 22 & 23.)
Recommendations
1. P B I repeat cholesterol, Start 5. Clotting time, prothrombin time,
thryoid gr. 1 daily. clot retraction, blood smear for
2. Stools for blood. Bland diet when platelets. Will give myltivitamin
tolerated. Maalox (antacid) (es- with at least 100 mg.C/day.
pecially in view of constipation 6. Ca and phosphorus.
problem) elevate head of bed. 7. ECG.
3. Urinalysis, culture if positive, 8. See 6/23 note.
BUN. Patient was examined by
4. Follow temp. and chart findings, E.N.T. consultant 5 weeks ago.
WBC and Differential. Laryngoscopy should be done.

Consulting Physician (signed)

280 IRISH JOURNAL OF MEDICAL SCIENCE

A u g u s t 21st :
1. Daughter states hoarseness present for years but getting worse. Doesn't take
medications at home regularly. (P.B.I. 1.0.)
2. Hgb. 12 grams. Reticuloeyte 1%. Will get C1. and CO 2 to evaluate possible G.I.
obstruction. I f abnormal, residual.
7. ECG same as 10 years ago. H e a r t size unchanged/x-ray.

August 22nd :
1. Cholesterol 353 mg. %.
2. Gastric aspiration--~18 Levine tube--30 c.c. yellowish viscid juice. P A - - A l k a l i n e -
although C1 down slightly (89) and CO 2 up to 29--doubt any obstructive factor. :No
stool obtained as yet.
3. U . T . o . k . / and urinalysis.
9 4. Chest x-ray clear. P a t i e n t wheezes when upset. :No nausea or vomiting for 48 hours.
5. Bleeding studies normal except positive tourniquet test. Believe problem either
vitamin deficiency or related to hypothyroidism.
6.
7. ECG :NL except low voltage as 10 years ago. Heart size :NL. P a t i e n t may have
angina but will re-evaluate this after myxedema improved. Believe patient all right
for discharge.
8. Class I V - - P A P smear.

August 23rd :
1. I n view of Class IV P A P smear, a change in plan as follows : Rapid euthyroidism
should be achieved in order t h a t D and C with biopsy and]or hysterectomy may be
accomplished in about 2 weeks.! Cytomel 25 mg./days 3. P a t i e n t to be followed by
Dr. in 3 and 6 days to increase dosage.
8. Dr. to do biopsy tomorrow and discharge patient to be given readmissiou
date in 2 weeks.
Consulting Physician (signed)

CASE 2
Chart I represents the day to day data sheet presented by a begin-
ning intern to his attending physician on work rounds. When there
are many patients to see each morning, no time can be lost in assembling
data at the time of rounds and no risks can be allowed based on ignor-
ance of all the available data. Charts like this shouldn't be limited to
patients with diabetic acidosis, a fifty per cent burn, or a scheduled
appearance at a conference. Questions similar to the following are only
possible and profitable when the right chart is immediately available.
Without the chart present at the time, the questions either never occur
to the teacher or their meaning completely escapes the beginner. For
example, on 8/20 the intern should be asked:

1. Could the unresponsiveness be caused by C'02 retention?

2. Is the absolute value of 29 meq. useful or should more attention

be paid to the rise from 23.5 to 29?

3. How is the value of 29 related to the pC02 and p i t values which

are better related to the patient's mental state?

4. Admitting the elementary fact that they are related through the
Henderson-Hasselbach equation, what are the temporal relation-
ships ?
O0
Z
Vit~ Signs Blood Values Intake Output Remarks
Time Urine
B.P. P. ~. V.P. Wgt. Sp. Hct. NA/t C]/HCOs NPN Calories Volume Pleural Phi. Total Dig.
Gray. Total Tap [ Mere.
e~
14/8 140/80 460 145
15/8 160/100 O0 143 46 140/4 04/23.5 ] 40 1,530 ' 1,880 0.8/2 c.c.
16/8 14o/oo 9O ii 185/190 1.011 40 910 450 0.1 Anti-coagulated
17/8 140/80 00-108 200/210 1,670 I 1,045 0.1 Gallop
18/8 140/80 72 010 840 I 350 0.1 Gallop
19/8 140/19 24 1,376 I 0.1 Gallop
< 2o/8 140/00 24 51 /20 37 377 5OO 0.1 Oxygen Tent removed. Un-
responsive in P.M. Pulse Diff.
to obtain. Catheterized--
500e.e.
2118 135/85 24 135 49 380 720 1,0O0 I 500 2,545 0.1 More alert. Voiding Spont.
22/8 130/80 18 521 1,810 3,810 0.1/2 c.c. Alert. happy
23/8 150/80 2O 127 41 86/35.8 560 1,970 815+ 0.1
24/8 150/80 24 128 784 1,650 1,200I 3,075 0.1
0 25/8 150/80 25 120 725 1,630 1,190 0.1
r..) 26/8 140/80 26 118 1.001 44 05/24.5 31 1,146 1,330 1,550 0.1/2 c.c.
27/8 130/80 22 116 1,346 1,770 1,620 0.1/2 c.c.
28/8 110 4O 91/ 0.1
"< 29/8 425 0.1/2 c.c.
I
282 IRISH JOURNAL OF MEDICAL SCIENCE

5. What regulates the lowering of pCO2 and an elevation of a

blood bicarbonate level and the pH?
6. How does the patient's renal disease affect these particular com-
pensatory mechanisms?
7. How long a time does compensation take following the retention
of CO2 ?
8. When should the intern draw another blood to get a third point
in the curve ?
9. How does the value of the haematocrit affect his decision to give a
diuretic ?
10. How high a value will he allow?
11. What are the dangers?
12. How high has he seen the haematocrit go under similar circum-
stances ?

The beginning intern should explain the massive drop in weight in

the light of the recorded fluid output, chest taps and the changing
haematocrits and the remarkedly stable respiratory rate and other vital
signs. If he questions the reliability of some of the values, why did he
not ,cross them out, or re-check them at the time ? The intern should be
told very clearly what questions the attending physician believes to be
unanswerable with current knowledge, but why the intern should read
and go beyond the attending's knowledge whenever possible. The intern
should learn, and keeping his own data is the best way for him to
learn, to integrate with great ease the attitudes of the investigator, the
daily care of his patient, and the excitement of following every routine
problem with its endless permutations and combinations of variables
that make every case different and make the practice of medicine,
research, whether he likes to call it that or not.