Chapter III HISTORY OF PATIENT (Continued)
WE next come to the patient’s present illness. It is im- portant to get as definite an idea as possible as to when this began. To do this it is better to ask Present the patient ‘‘ When did you last feel perfectly MES well? ”’ rather than the customary question, ‘““ When did you first feel sick? ’’? The an-, swer to the first question will usually antedate the second by many months and will be far nearer the truth. With this as a starting-point one should next find out what was the first symptom noticed, and how soon after this the patient consulted a doctor. In many cases the first symptom is found to be a constitutional one, such as loss of strength or energy, fever, etc., rather than one which could be referred directly to the lungs. Of all the constitutional symptoms an unexplained loss of weight is the most important, especially when combined with loss of strength and energy. Comets In some cases of early tuberculosis there tional f ‘ Signs aad may be little or no loss of weight; usually, Symptoms. | however, there has been a loss even though slight. The maximum weight and its date, the normal weight, which is rarely the maximum, and the present weight should all be ascertained and recorded. In some cases a marked loss can be so satisfactorily ex- plained as to lose all significance. It not in- Loss of frequently happens that recent immigrants clan to this country will state that they have lost ten or twenty pounds since their arrival. This does not necessarily mean disease, but is merely the effect of more strenuous living amid strange and perhaps trying 20
EARLY PULMONARY TUBERCULOSIS 21
conditions. Likewise a gradual loss of weight over a period of many years is not of much importance. It is often the case with patients in middle life that they reached their maximum weight ten or twenty years ago, but that this has gradually declined to a point they now regard as perfectly normal. Unless, however, a loss of weight can be satisfactorily explained in some such way as this, it is an important symptom. Along with loss of weight there is apt to be an unex- plained loss of strength; the patient is apt to complain of languor or undue weariness. This combi- Loss of nation is of the greatest importance and by poet itself is sufficient reason for a careful lung examination. The patient may state that he gets tired and out of breath more easily and more quickly than before; that everything is an effort; the legs ache; that it is harder to go upstairs and more tiring to go to and from work than formerly, and (of special signifi- cance) that a good night’s sleep no longer seems to bring the rest and renewed strength in the morning that was formerly the case. It must be borne in mind, however, that this phenomenon may also occur in many neurotic states. All this should be carefully gone into as possible important points in diagnosis. There is no commoner symptom of a tuberculous toxemia than what is described as ‘‘ loss of ambition and energy.’’ Patients on questioning will admit
Loss of that without knowing why, they have lost in- peli! terest in their work and in life in general; nergy.
that they no longer enjoy living as they did. Often, if the patient himself does not admit it, parents or friends will call attention to the fact that there has been a marked change in temperament; that a patient formerly good-tempered and easy to live with has be- come cross and disagreeable; that the patient has become nervous, irritable and easily upset by little things. Tuber- culosis may not be the cause of these changes; only too
22 EARLY PULMONARY TUBERCULOSIS
frequently, however, subsequent events prove that it was.
Loss of appetite, a capricious appetite and all sorts of dyspepsias variously diagnosed as hyperacidity, atony,
hypomotility, ete, may be the first indica- Loss of tion that a tuberculous focus is active some- ANH. where in the body. <A loss of appetite par-
ticularly for breakfast is common in early tuberculosis.
Nothing will give the physician more information as to diagnosis, prognosis and treatment than a careful
study of the patient’s temperature and pulse. moraine These observations should be made under and Pulse, | 2ormal conditions at home by some reliable
person other than the patient whenever pos-
sible. Temperature and pulse taken in a physician’s office are notoriously unreliable, but careful records at 8 a.m., 12 m., 4 p.m. and 8 p.m. over a period of not less than four days will give evidence of great value. Whether the thermometer is a one-minute or a three-minute instrument, it should be kept in the mouth full five minutes with the patient at rest. It should be borne in mind that a slight elevation of temperature, fifteen to thirty minutes after meals, is normal in health and that the temperature should therefore be taken be- fore meals or some time after them. It is also important to remember that there is apt to be slight fever just be- fore the menstrual period and during the first two days of it. Slight fever at such a time has not the significance it would otherwise have. If the stethoscope were used less and the thermometer more, fewer mistakes would be made.
The importance of any persistent though slight rise in temperature above normal is well known; the equal or even greater importance of a constantly subnormal temperature combined with a rapid pulse, over 100 or 110, has not been sufficiently emphasized. A high pulse
EARLY PULMONARY TUBERCULOSIS 23
and subnormal temperature, associated with other con- stitutional symptoms, is of as much importance in diag- nosis as a slight degree of fever, and in prognosis of far graver significance. In no other disease are relatively slight variations in temperature so important. Com- bined with a loss of weight and strength and other sus- picious constitutional symptoms, a slight afternoon fever up to 99.2° or 99.4°, or a constantly subnormal tempera- ture with rapid pulse may be considered as almost path- ognomonie of a tuberculous infection and justifies a posi- tive diagnosis whether or not definite signs are found in the lungs. Pallor does not always mean anemia. The hemoglobin should be taken in every case and if found to be seventy per cent or lower may be of significance in Loss of diagnosis. One occasionally finds a moderate Hat amount of anemia in the early stages. This is sometimes called ‘‘ tuberculous chlorosis.”’ It is not a true chlorosis, however, nor can it be regarded as a clinical entity, but merely a secondary anemia which is apt to occur in young women with incipient tuber- culosis. Flushes and chilly feelings are frequently met with in the early stages of the disease. Actual vasomotor chills and night sweats are rare. In the Disturbances. early stages these phenomena simply show an unstable and irritated vasomotor appa- ratus and are of minor importance in diagnosis. Hoarseness due to relaxation of the vocal Hoarseness. cords and not to any tuberculous process is , not uncommon in delicate patients and is an early symptom. Menstrual irregularities are common but Menstrual of little diagnostic value. aoe Among the many constitutional signs and symptoms which careful and systematic ques- tioning on the part of the physician may elicit and
24 EARLY PULMONARY TUBERCULOSIS
which show that a tuberculous process is somewhere actively at work in the system, the most important are, first, an unexplained loss of weight, Summary of Strength and nervous energy, and next, a Important —_ pulse constantly over 100-110 with the patient EHS at rest, with a slight fever or a subnormal temperature with afternoon or evening rise to 99.2° or 99.4°. In the great majority of instances such a combination of constitutional signs and symptoms means tuberculosis and demands radical treatment.