Friday, 22 April 2016

What does that mean? The challenges of case note cataloguing

This week, Rebecca looks at one of the main challenges she faces in the RVH v TB project:
Cataloguing case notes can be quite a challenging task when you don’t have a medical background. Although we are interpreting the records, and not diagnosing patients, it is still important for us to understand what we are reading so that we can record the important information in our catalogues.
Firstly, doctors’ handwriting is notoriously difficult to read! Additionally, unfamiliar terms and abbreviations are often used (e.g. ‘syncope’ instead of ‘fainting’), medical terms for body parts are not always recognisable (my new knowledge from this project has won me many a point in a pub quiz), and some of the terms used are no longer in use.
Fortunately, there are web resources that can help. A combination of palaeography skills and Google usually helps to make sense of tricky handwriting. Google is also great for finding out what unfamiliar terms mean, as well as unexpectedly showing gruesome pictures of some medical conditions; my search history paints a worrying picture. We also use MeSH (Medical Subject Headings), a hierarchically organised index of medical terminology, to provide standardised terms – MeSH usually incorporates alternative and previous terms into its definitions, which is really useful.
These tools are great for standard medical terms and abbreviations, which makes up much of the case notes that we look at. However, in the RVH v TB case notes, some non-standard symbols are used which has required some detective work from me:
Samples from case notes showing different ways of expressing 'Tuberculosis' (see below) (LHB41 CC/1 and CC/2)
All of these symbols mean ‘Tuberculosis’. Here’s how I know that:
1.       This classification was used at Southfield Sanatorium. In his “Address in Medicine Delivered at the Seventy-Seventh Annual Meeting of the British Medical Association” in 1909, Sir Robert William Philip advocates a system of classification of tuberculosis which uses the symbol ‘L’ to represent the lung or local lesion, with three stages of severity. The symbol ‘S’, in upper or lower case, represents the extent of systemic involvement.
2.       The next two symbols (actually the same symbol written in two ways), usually appear in place of the word “tuberculosis” in the sentences “No family history of tuberculosis” or “No PS [physical signs] of tuberculosis”, and is sometimes used to represent a diagnosis.
3.       This classification was used at the Royal Victoria Dispensary, and has been a little trickier to work out. Based on what else is happening in the case notes in which it appears, where a patient has been subsequently hospitalised or a later letter refers to them as being diagnosed with tuberculosis, it definitely means tuberculosis, and it appears to have a similar grading scale as Philip’s classification above.
4.       This is another version of the same classification scale, also used at RVD, and seems to show a diagnosis of a quiescent or less active case of tuberculosis.
5.       This is the classification used at the Royal Victoria Hospital, which is helpfully explained on the back of the discharge summary (see below).
Reverse of a discharge summary from the Royal Victoria Hospital, explaining the classification scheme (LHB41/PR2.4347)
Those were all relatively straightforward to work out, but these things are never too simple. The case notes from the Royal Victoria Dispensary also feature the symbols shown as a diagnosis in the examples below, which I have so far been unable to ascertain the meaning of.
Extracts from case notes, showing X-ray reports and the diagnosis given. (LHB41 CC/2)
The case notes in which they appear lack the context which has helped in other cases, and there doesn’t seem to be much consistency across the case notes which would allow me to say with confidence that this means, for example, bronchitis, though it is almost definitely a lung thing. As the image shows, it sometimes appears alongside a TB diagnosis, so it probably isn’t tuberculosis.  If you have any ideas what it might mean, I’d be really grateful to hear them!
As you can see, a medical background is not necessary in order to catalogue the case notes, though some medical knowledge can really help when it comes to understanding them, particularly when they start using obscure terminology or symbols. Fortunately, we have the resources to deal with these challenges, which means that we can create useful catalogues to help unlock these fascinating records.
LHB41 CC/1 and CC/2
R. W. Philip, ‘Address in Medicine Delivered at the Seventy-Seventh Annual Meeting of the British Medical Association’, British Medical Journal, 2, 2535, (31 July 1909), pp. 256-263

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