The examiner has by this time formed some concept of the case in hand. He has a clue to the possible nature of the disease and he has narrowed his observation to a few segments of the body or a few organs which demand a more special examination. This may be accomplished by Inspection, Palpation, Auscultation, and Percussion.
History of Case
Having determined by these methods every fact possible of determination without information from the patient, it becomes necessary to go somewhat into the history of the case. The history of falls, jars, shocks, or injuries of any kind should be taken first and these should be viewed in the light of their bearing upon the previously ascertained condition of the spine. Sometimes the definite history of an accident immediately preceding the development of disease symptoms suggests its connection with the disease and the exact nature of the accident points out to us some one of the several recorded subluxations as the one involved. This in turn may aid a doubtful differential diagnosis. Each step in the process of examination helps to explain and clarify the facts elicited by other steps until the facts marshal themselves into a complete and comprehensible picture.
At this point it will be possible to stop in some cases and rest upon the evidence gathered. If you are able at this time to state clearly the nature of the case, the manner of its cause, the site of disease and of the subluxations causing it, the kind of subluxations, and the chance of recovery under adjustment, it is preferable to do so. You will thus have made a complete diagnosis without recourse to information from the patient except the history of injuries.
Sometimes, however, it will be necessary to go further into the case and ascertain the presence and nature of subjective symptoms. If this be necessary, the examiner should confine his questions to the parts indicated as diseased, and thus limit the number of questions and make them all direct and essential. It is important to avoid trivial or irrelevant questioning.
Summary
Finally, having ascertained all necessary facts, mentally summarize them all, combining the results of Palpation, Nerve-Tracing, and Symptomatology so as to reach a definite conclusion as to the location and nature of the morbid process, the subluxation producing it, and the exact form of adjustment necessary to correct it.
The examiner should be able at the end of the examination to state exactly what he finds to be the condition of the patient, to give reasons and nerve connections, and to demonstrate a subluxation to back every statement.
The case record should contain all essential information relating to the diagnosis and the correction to be applied.