The Use of Force

By William Carlos Williams

They were new patients to me, all I had was the name, Olson. Please come down as soon as you can, my daughter is very sick.

When I arrived I was met by the mother, a big startled looking woman, very clean and apologetic who merely said, Is this the doctor? and let me in. In the back, she added. You must excuse us, doctor, we have her in the kitchen where it is warm. It is very damp here sometimes.

The child was fully dressed and sitting on her father's lap near the kitchen table. He tried to get up, but I motioned for him not to bother, took off my overcoat and started to look things over. I could see that they were all very nervous, eyeing me up and down distrustfully. As often, in such cases, they weren't telling me more than they had to, it was up to me to tell them; that's why they were spending three dollars on me.

The child was fairly eating me up with her cold, steady eyes, and no expression to her face whatever. She did not move and seemed, inwardly, quiet; an unusually attractive little thing, and as strong as a heifer in appearance. But her face was flushed, she was breathing rapidly, and I realized that she had a high fever. She had magnificent blonde hair, in profusion. One of those picture children often reproduced in advertising leaflets and the photogravure sections of the Sunday papers.

She's had a fever for three days, began the father and we don't know what it comes from. My wife has given her things, you know, like people do, but it don't do no good. And there's been a lot of sickness around. So we tho't you'd better look her over and tell us what is the matter.

As doctors often do I took a trial shot at it as a point of departure. Has she had a sore throat?

Both parents answered me together, No . . . No, she says her throat don't hurt her.

Does your throat hurt you? added the mother to the child. But the little girl's expression didn't change nor did she move her eyes from my face.

Have you looked?

I tried to, said the mother, but I couldn't see.

As it happens we had been having a number of cases of diphtheria in the school to which this child went during that month and we were all, quite apparently, thinking of that, though no one had as yet spoken of the thing.

Well, I said, suppose we take a look at the throat first. I smiled in my best professional manner and asking for the child's first name I said, come on, Mathilda, open your mouth and let's take a look at your throat.

Nothing doing.

Aw, come on, I coaxed, just open your mouth wide and let me take a look. Look, I said opening both hands wide, I haven't anything in my hands. Just open up and let me see.

Such a nice man, put in the mother. Look how kind he is to you. Come on, do what he tells you to. He won't hurt you.

At that I ground my teeth in disgust. If only they wouldn't use the word "hurt" I might be able to get somewhere. But I did not allow myself to be hurried or disturbed but speaking quietly and slowly I approached the child again.

As I moved my chair a little nearer suddenly with one catlike movement both her hands clawed instinctively for my eyes and she almost reached them too. In fact she knocked my glasses flying and they fell, though unbroken, several feet away from me on the kitchen floor.


Both the mother and father almost turned themselves inside out in embarrassment and apology. You bad girl, said the mother, taking her and shaking her by one arm. Look what you've done. The nice man . . .

For heaven's sake, I broke in. Don't call me a nice man to her. I'm here to look at her throat on the chance that she might have diphtheria and possibly die of it. But that's nothing to her. Look here, I said to the child, we're going to look at your throat. You're old enough to understand what I'm saying. Will you open it now by yourself or shall we have to open it for you)

Not a move. Even her expression hadn't changed. Her breaths however were coming faster and faster. Then the battle began. I had to do it. I had to have a throat culture for her own protection. But first I told the parents that it was entirely up to them. I explained the danger but said that I would not insist on a throat examination so long as they would take the responsibility.

If you don't do what the doctor says you'll have to go to the hospital, the mother admonished her severely.

Oh yeah? I had to smile to myself. After all, I had already fallen in love with the savage brat, the parents were contemptible to me. In the ensuing struggle they grew more and more abject, crushed, exhausted while she surely rose to magnificent heights of insane fury of effort bred of her terror of me.


The father tried his best, and he was a big man but the fact that she was his daughter, his shame at her behavior and his dread of hurting her made him release her just at the critical times when I had almost achieved success, till I wanted to kill him. But his dread also that she might have diphtheria made him tell me to go on, go on though he himself was almost fainting, while the mother moved back and forth behind us raising and lowering her hands in an agony of apprehension.

Put her in front of you on your lap, I ordered, and hold both her wrists.

But as soon as he did the child let out a scream. Don't, you're hurting me. Let go of my hands. Let them go I tell you. Then she shrieked terrifyingly, hysterically. Stop it! Stop it! You're killing me!


Do you think she can stand it, doctor! said the mother.

You get out, said the husband to his wife. Do you want her to die of diphtheria?

Come on now, hold her, I said.

Then I grasped the child's head with my left hand and tried to get the wooden tongue depressor between her teeth. She fought, with clenched teeth, desperately! But now I also had grown furious--at a child. I tried to hold myself down but I couldn't. I know how to expose a throat for inspection. And I did my best. When finally I got the wooden spatula behind the last teeth and just the point of it into the mouth cavity, she opened up for an instant but before I could see anything she came down again and gripping the wooden blade between her molars she reduced it to splinters before I could get it out again.

Aren't you ashamed, the mother yelled at her. Aren't you ashamed to act like that in front of the doctor?

Get me a smooth-handled spoon of some sort, I told the mother. We're going through with this. The child's mouth was already bleeding. Her tongue was cut and she was screaming in wild hysterical shrieks. Perhaps I should have desisted and come back in an hour or more. No doubt it would have been better. But I have seen at least two children lying dead in bed of neglect in such cases, and feeling that I must get a diagnosis now or never I went at it again. But the worst of it was that I too had got beyond reason. I could have torn the child apart in my own fury and enjoyed it. It was a pleasure to attack her. My face was burning with it.

The damned little brat must be protected against her own idiocy, one says to one's self at such times. Others must be protected against her. It is a social necessity. And all these things are true. But a blind fury, a feeling of adult shame, bred of a longing for muscular release are the operatives. One goes on to the end.

In a final unreasoning assault I overpowered the child's neck and jaws. I forced the heavy silver spoon back of her teeth and down her throat till she gagged. And there it was--both tonsils covered with membrane. She had fought valiantly to keep me from knowing her secret. She had been hiding that sore throat for three days at least and lying to her parents in order to escape just such an outcome as this.

Now truly she was furious. She had been on the defensive before but now she attacked. Tried to get off her father's lap and fly at me while tears of defeat blinded her eyes.

verbi irregolari

eccovi un link per andarvi a riguardare un po' di verbi irregolari.
l'elenco che trovate nella prima pagina presenta anche delle traduzioni di massima. fateci attenzione in quanto quei significati sono alquanto riduttivi e, in alcuni casi, fuorvianti.
ecco il link >>

How to take a history

Start by putting the patient at ease:

• Greet the patient by name: "Good morning, Mrs Jones"
• Introduce yourself and explain that you are a medical student.
• Shake the patient's hand, or if they are unwell rest your hand on theirs.
• Ensure that the patient is comfortable.
Standard history taking

• Name
• Address
• Date of birth
• Date of admission
• Presenting complaint
• History of presenting complaint
• Previous medical history
• Systems enquiry
• Drug history and allergy
• Family history
• Social history
• Conclusion/summary

General questions to ask the patient:

• Tell me what seems to be the problem.
• How long have you been unwell?
• When did the symtoms start?
• Not What brought you here?

History of presenting complaint
If the history of the presenting complaint includes pain, ask about it using the
mnemonic SOCRATES
• Site - where exactly is this pain?
• Onset - when did the pain start, did it start suddenly or gradually?
• Character - describe the pain - sharp? knife-like? gripping? vice-like?
burning? crushing?
• Radiation - does the pain spread anywhere? To the arm, jaw, groin
etc?
• Associations - is the pain accompanied by any other features?
• Timing - does the pain vary in intensity during the day?
• Exacerbating and relieving factors - does anything make the pain better
or worse?
• Severity - does the pain interfere with daily activities or with sleep?

Questions to ask about previous medical history

General question:

• Have you suffered from any previous illness?
Medical
• Ask about childhood illness and immunization
• Have you had TB or whooping cough?
• Have you ever been found to have high blood pressure?
• Have you had rheumatic fever?
• Have you ever suffered from epileptic seizures?
• Do you get asthma (episodic breathlessness, usually with wheeze)?
• Have you suffered from anxiety or depression?
• Do you have diabetes?
Surgical
• Have you had any operations in the past?
Obstetric (where appropriate)
• Have you had any pregnancies?
• Were they normal?
• Were there any complications such as hypertension and toxaemia,
diabetes, Caesarian section?
You may find the mnemonic THREAD helpful:
• Tuberculosis
• Hypertension (myocardial infarction and strokes)
• Rheumatic fever
• Epilepsy
• Astham, anxiety and arthritis
• Diabetes and depression


Systems Enquiry

Questions to ask patients about their general health:

Cardiovascular and respiratory function
• Do you have a cough?
• Do you cough anything up?
• Have you ever smoked? If so what, how many, and for how long?
• Do you get short of breath?
• Do you wheeze?
• Do you get any chest pain?
• Do your ankles swell?

Gastrointestinal function
• Has there been any change in your appetite?
• Has there been any change in your weight?
• Have you suffered from nausea or vomiting?
• Has there been any change in the character or frequency of your bowel
movements?
• Has there been any change in the colour or consistency of your stools?
• Have you had any bleeding? - while vomiting (haematemesis) or
rectally?

Genitourinary function
• How often do you pass urine?
• Do you have pain or burning on passing urine?
• Do you have pain in the small of your back (renal angles)?
• Is there any blood in your urine (haematuria)?
• Do you have any sexual problems?

Specific questions for men
• Do you have any penile discharge or venereal infection?
• Do you have any difficulty starting to pass urine (hesitancy or urgency),
maintaining the flow of urine (poor stream), or stopping the flow of urine
(terminal dribbling)?

Specific questions for women
• Do you have any vaginal discharge?
• When did your periods start?
• Are your periods irregular?
• How often do your periods occur and for how long do they last?
• Do you have heavy bleeding (menorrhagia) or do you pass clots during
your period?
• When did your periods stop (menopause)?
• Have you had any bleeding since your periods stopped?
• How many children have you had and when did you have them?
• Did you have any complications during any pregnancy?

Musculoskeletal function
• Have you any weakness in your arms or legs?
• Do you have any stiffness in your joints or spine?
• Do you have pain in your joints or spine?

Neurological function
• Do you have any headaches?
• Have you had any blackouts?
• Have you had any fits?
• Have you had any dizziness (feeling of instability or rotation)?
• Do you get ringing in your ears (tinnitus)?
• Do you get abnormal sensations or tingling in your hands or feet
(paraesthesia)?
• Have you noticed changes in your sense of hearing, smell, taste,
vision?
• Have you any incontinence of urine or stools?
• Do you get depressed?
• Do you get anxious?

Drug history and allergies
• What drugs, homoeopathic and herbal medicines and/or health foods
do you take? - and in what dose?
• What other therapies do you have? - Physiotherapy? Occupational
therapy? Malaria prophylaxis?
• Do you have any allergies?
• Have any medicines ever upset you?
Return to the top of the page

Family history
• Are your father, mother, brothers, sisters alive? - If they have died, at
what age did he/she/they die? What did he/she/they die of?
• Do they have any current illnesses?
• Do any illnesses run in your family?
Return to the top of the page

Social history
• Who is at home with you?
• Are you single, married, widowed or divorced?
• Is your partner healthy?
• How many children have you got?
• Are your children healthy?
• What is your occupation?
• Do you have any financial worries?
• Do you smoke? - If so, how may per day/week?
• Have you ever smoked? - Why did you give up?
• Do you drink alcohol? - If so, how many units per day/week?
• Have you been abroad? - If so, where?
• Do you have pets?
• If mobility is a problem: What is your home like? Do you have to
manage stairs? What facilities have you got?

Conclusion/summary
After you have taken the history summarize your findings under appropriate
headings. Once you have completed the history ask the patient whether they
have any other particular worries or concerns that you hve not discussed.
Thank the patient and explain, if appropriate, that you would now like to
examine them.

Summary

Date and time
Place of
consultation
Patient's name, age
and occupation
Presenting
complaint
Summarize both the current problem and the means by which the
patient came to medical attention
e.g. - referred by GP, with a 3 hour history of severe central chest
pain, - brought to the Accident and Emergency department by
boyfriend after taking an overdose of paracetamol
History of present illness
Detailed account of current problem
If complaint is pain, remember SOCRATES
Systematic enquiry
Take detailed supplementary questions if responses are positive
Cardiovascular and respiratory
Gastrointestinal
Genitourinary
Neurological
Musculoskeletal
Psychiatric assessment (where appropriate)
Past medical history

Medical:
• TB
• Hypertension
• Rheumatic fever
• Epilepsy
• Asthma
• Diabetes
Surgical
Obstetric
Family history Age and state of health of parents and siblings
Social,
occupational and
travel history
Drug and therapy
history include allergies

More on acronyms

a.c.: Abbreviation on a prescription meaning before meals; from the Latin "ante cibum", before meals. This is one of a number of hallowed abbreviations of Latin terms that have traditionally been used in writing prescriptions.

Some others:

b.i.d. = twice a day (from "bis in die", twice a day)
gtt. = drops (from "guttae", drops)
p.c. = after meals (from "post cibum", after meals)
p.o. = by mouth, orally (from "per os", by mouth)
p.r.n. = when necessary (from "pro re nata", for an occasion that has arisen, as circumstances require, as needed)
q.d. = once a day (from "quaque die", once a day)
q.i.d. = four times a day (from "quater in die", 4 times a day)
q._h.: If a medicine is to be taken every so-many hours (from "quaque", every and the "h" indicating the number of hours)
q.h. = every hour
q.2h. = every 2 hours
q.3h. = every 3 hours
q.4h. = every 4 hours
t.i.d. = three times a day (from "ter in die", 3 times a day)
ut dict. = as directed (from "ut dictum", as directed)

a basic ST acronym list

AAC = Augmentative and Alternative Communication
ABA = Applied Behavior Analysis
ADD = Attention Deficit Disorder
ADHD = Attention Deficit Hyper Disorder
AIT = Auditory Integrated Training
AOS = Apraxia of Speech
APD = Auditory Processing Disorder
ASD = Autism Spectrum Disorder
ASQ = Ages and Stages Questionnaire
ASL = American Sign Language

BCH = Benign Congenital Hypotonia

(C)APD or CAP or APD = Central Auditory Processing Disorder
CELF = Clinical Evaluation of Language Functions (Preschool-3 to 6 years-
language test)
CELF 3 = Clinical Evaluation of Language Functions (3 to 21 years - language
test)
CHERAB = Communication Help, Education, Research, Apraxia Base
CPSE = Committee on Preschool Special Education
CTONI = Comprehensive Test of Nonverbal Intelligence
CV = Consonant Vowel

DAS = Developmental Apraxia of Speech
DDR = Developmental Delay Resources
DHA = Docosahexaenoic acid
DOE = U.S. Department of Education
DSI = Dysfunction of Sensory Integration (another acronym for SID)
DVD = Developmental Verbal Dyspraxia

EEG = Electroencephalogram
EHCA = Education for All Handicapped Children Act
EI = Early Intervention
EMG = Electromyography
EOWPVD = Expressive One-Word Picture Vocabulary Test-Revised (2-12 years
language test)

FMRI = Functional magnetic resonance imaging

GER = Gastro-esophageal reflux
GFDA = The Goldman-Fristoe Test of Articulation
GI = Gastro-intestinal

IDEA = Individuals With Disabilities Education Act
IEP = Individualized Education Plan
IFSP = Individualized Family Service Plan
IQ = Intelligence Quotient

KSPT = The Kaufman Speech Praxis Test for Children (24 to 71 months)

LD = Learning Disabled
LDA = Learning Disabilities Association of America
LLD = Language-based Learning Disability
LiPS = Lindamood Phoneme Sequencing Program
LRE = Least Restrictive Environment

M.D. = Medical Doctor
MIND = Music-Intelligence-Neural-Development
MIT = Melodic Intonation Therapy
MR = Mentally Retarded
MRI = Magnetic Resonance Imaging

NDT = Neurodevelopmental Treatment
NICHY = National Information Center for Children and Youth With Disabilities
NIH = National Institutes of Health
NIDCD = National Institute on Deafness and Other Communication Disorders

OT = Occupational Therapy or Occupational Therapist

PAT = The Photo Articulation Test
PDD = Pervasive Developmental Disorder (milder end of the Autism Spectrum)
PDD-NOS = Pervasive Developmental Disorder Not Otherwise Specified
PECS = Picture Exchange Communication System
PEDS = Parents' Evaluation of Developmental Status
PLS 3 = Preschool Language Scale
POWPVT = Receptive One-Word Picture Vocabulary Test (2-18 years, language
test)
PROMPT = Prompts for Restructuring Oral Muscular Phonetic Targets
PT = Physical Therapy or Physical Therapist

SD = School District
SEPTA = Special Education Parent Teacher Association
SERT= Special Education Resource Teacher
SETRC = Special Education Training and Resource Center
SI = Speech Impaired or Sensory Integration
SII = Sensory Integration International (The Ayres Clinic)
SID = Sensory Integration Dysfunction (now referred to as DSI)
SLI = speech language impairment
SLP = Speech Language Pathologist
SMO = Supramalleolar orthotics
ST = Speech Therapy

TBI = Traumatic Brain Injury
TELD-3 = Test of Early Language Development (2 -7 years language test)
TX = Treatment

VMPAC = Verbal Motor Production Assessment for Children (3 -12 years)

Processing a history

Process



A practitioner typically asks questions to obtain the following information about the patient:

- Identification and demographics: name, age, height, weight.
- The "chief complaint (CC)" - the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).
- History of the present illness (HPI) - details about the complaints, enumerated in the CC. (Also often called 'History of presenting complaint' or HPC.)
- Past Medical History (PMH) (including major illnesses, any previous surgery/operations, any current ongoing illness, e.g. diabetes).
- Review of systems (ROS) Systematic questioning about different organ systems
- Family diseases - especially those relevant to the patient's chief complaint.
- Childhood diseases - this is very important in pediatrics.
- Social history (medicine) - including living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets.
- Regular and acute medications (including those prescribed by doctors, and others obtained over-the-counter or alternative medicine)
- Allergies - to medications, food, latex, and other environmental factors
- Sexual history, obstetric/gynecological history, and so on, as appropriate.

History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians). Computerized history-taking could be an integral part of clinical decision support systems.

Medical History

Again out of wikipedia english, the basic definition of Medical History

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The medical history or anamnesis (abbr. Hx) of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.