Art of Case taking in Homeopathy

Steps in case taking
Case taking can be summarized into following stages

1.Stage of observation

When the patient enters into the consulting room the following features Should be carefully noted.

1.    Note the facial appearances and expressions of the patient- plethoric , Waxy, pale, puffy, edematous, myxoedematous,& so on

2.    Note whether the patient is anxious, angry, cruel, cunning, stupid, etc.

3.    Depressed patient has vertical furrows on the brow, turning down of the corners of the mouth, sits leaning forward, with shoulders hunched, the head inclined downwards and gaze directed to the floor. Anxious patient generally have horizontal creases on the forehead, raised eyebrows widened palpebral fissure, and dilated pupils. They usually sit upright with head erect often at the edge of the chair with hands gripping the sides and are restless.

4.    The peculiarity of gait. E.g.; ataxic, reeling, spastic, etc.

5.    Attitude-any form of rigidity, kyphosis, lordosis, parkinsonian attitude, etc

6.    Temperature and atmosphere of the room- when the patient enters the room observe whether he comes over clad or under clad, demands fanning (in winter) or off (even in hot weather) & so on

7.    Any bad odor its nature and source.

8.    Mood of the patient- depressed, worried, anxious, timid, irritable, indifferent, fastidious, comatose, delirium, and so on.

2.Stage of listening to the complaints

II. Listening to the complaints.
First from the patient and then from the attendants.
It is very delicate yet dynamic situation, where a physician should remain attentive so that disclosures are received properly. Do not interfere while narration unless they wander off to some irrelevant matters. He should involve in active listening
3.Stage of interrogation and cross-examination
4.Stage of clinical examination
5.Laboratory investigations
6.Stage of diagnosis

III. Stage of interrogation cross examination
Now fill the gaps left in the just previous stage in order to complete the symptoms with respect to their location, sensation, and modalities. Cross-examine the patient and attendants to classify the data. This is the most difficult stages case taking. It necessitates sufficient sympathy, patience, introspection and tactfulness on the part of the physician. Any hurry or bluntness will completely spoil the whole picture of the case.

IV. Stage of clinical examination
General examination and examination of various organs and systems.

V. Stage of laboratory investigations.
To confirm the provisional diagnosis and for the management and prognosis.

VI. Stage of diagnosis of the case
Different forms of diagnosis are
1.Pathological diagnosis- disease diagnosis
2.Etiological diagnosis- exciting and maintaining cause of the disease
3. Chronic miasmatic diagnosis- The fundamental cause of the disease
4. Personality diagnosis- Peculiar constitutional, temperamental and Mental
behavior, cravings and aversions, peculiar reactions to Environmental
Condition, rest, movements, etc.
5. Therapeutic diagnosis.-Depending on outstanding individualizing
Peculiarities elicited under the above noted investigations.

Qualities of a physician conducting inquiry.
Aphorism-83.
1.Freedom from prejudice- Prejudice means judging the present on the basis of past experience, which lead to a fixity rigidity of thinking. Physician should not use his own yardsticks and parameters to understand the case. For the time being he should detach himself from his own past experiences, his emotions, desires and aversions and physical reactions. The only way to become unprejudiced is to become aware of our prejudices. Prejudice and doubt may be overcome by reflection, study, self discipline and auto suggestion by cultivating the scientific spirit
2. Sound senses. – Inorder to obtain a complete picture of the disease one has to know what to notice and where to look for in a given case. A physician’s sense can be called sound only if he is capable of utilizing them in an undisturbed uninterrupted and unbiased way. It depends on the sensitivity and commitment of the physician to his profession.

3. Attention in observing- A careful observer alone can become a true healer of disease. Inorder accurately to perceive what is to be observed in patients, we have to come out of ourselves and attach ourselves with all powers of concentration upon the subject. Poetic fancy, fantastic wit, and speculations must, for a while, be suspended and all overstrained reasoning, forced interpretation and tendency to explain away things must be suppressed. His attention should be on the watch that nothing actually present escape his observation and also what he observes be understood exactly as it is. The capability should be acquired by practice and the best opportunity for exercising and perfecting our observing faculty is afforded by instituting experiments with medicines upon ourselves.

4.Fidelity in tracing the picture of the disease- A physician should be faithful and loyal in noticing and recording the deviation from the health with firm adherence to the principles of a medical profession especially homoeopathy. He should be able to translate his observations into words by using the most appropriate expressions.

Some hints on case taking
When the patient is telling the history always watch his gestural language to see if it matches his words. You should make it feel that the patient has your whole attention and that you will not be shocked or angered by anything he says. Gazing out of the window or continually writing notes will put off the patient. Never underestimate the power of communication inherent in touching your patient. It will give more comfort than your words of reassurance. Gentle and thorough physical examination is important in gaining patient’s confidence

1.The best totality of symptoms would include mainly those symptoms From which one can get no clue about or which do not depend upon the patients age, nationality, occupation, or pathology.
2. Symptoms existed prior to the situation or priors to the pathology are Important. We have to remove those that are explainable by the Patients situations and pathology.
3. Symptoms provided by the patient should be accepted with interest but without judgement. If the patient feels judged he will likely withdraw within himself

Difficulties in taking a chronic case
1.Patients coming from other physicians
In case of patients with previous course of medicines, the true symptom image of the patient may have altered or have been mixed up with the symptoms of drugs . In such cases those symptoms and ailments which he suffered from before the use of the medicines or after they had been discontinued for several days give true fundamental idea of the original form of the disease
2.Accustomed long sufferings
The patient due to several years of sufferings get accustomed to certain symptoms and fail to mention thinking that these symptoms might be minor and insignificant and feels that these accessory symptoms do not have any connection with their main complaints. These symptoms are sometimes important in arriving a totality
3.Hypochondriacs and hypersensitive patients
These persons impatient of their sufferings exaggerate their sufferings to induce the physician to give them relief. Hypochondriacs
Imagines complaints where the hypersensitive overstates the complaints
4.Modesty conceals the facts
Some individuals do not take much interest in describing their ailments. They can be called stoics. They refrain from mentioning
The symptoms or describe in vogue terms due to indolence, false modesty, or from a kind of mildness of disposition or weakness of mind. They thinks that there is no need of telling everything about the health and disease as the physician’s attention may be diverted from the chief complaint.
5.Long suffering considered incurable
Here owing to the long period of suffering the patient thinks the disease is incurable and refrain from mentioning
6.Intellectuals
Intellectuals tend to relate to reality according to what is explainable to their
minds . They evaluate or interpret their symptoms in terms of their knowledge and philosophy of life and explain away the very symptoms of most value to the homoeopath
They adopt some theories on diet and regimen without any consideration for the uniqueness of their organisms, keeping aside their desires and aversions and causing missing of valuable data to a homoeopath
7.In chronic cases physician should give more importance to the patient’s own description of the suffering. Patient can alone describe his suffering and sensations accurately and exactly and by the friends and attendants they are usually altered and erroneously stated.

AN OUT LINE OF CASE TAKING:
Actual questions in a given case will be guided by the nature of illness itself. Great flexibility must be allowed in inquiring these things so that the patient can be as expressive as possible.Any symptoms of great meaning to the patient which is given with great descriptive clarity, great intensity causing interference in the life of the patient and spontaneity ie, volunteered by the patient rather than elicited after questioning carries the highest value in a case.

I. DETAILS OF THE PATIENT
Name
Age
Sex
Occupation
Address
Religion
Marital status
Address and phone of the nearest relative
Date
Reg. No.

Relevance
Name: Patients generally like to be asked by name that creates a friendly atmosphere in the consulting room
Age: There are medicines in our materia medica having affinity to diseases occurring in certain ages as well as there are diseases occurring more frequently at certain ages . The rubrics related are,

New born- Resp. Asphyxia children new born
Rectum constipation children new born
Bladder retention children new born
Skin discoloration yellow children new born
Children; Respiration Asthmatic children
Rectum diarrhea children
Adolescence- Bladder urination Invol. Night adolescence
Puberty: Generalities puberty ailments in
Young people: Head hair baldness young people
Menopause: Female menopause
Old people: Resp. asthmatic old people
Eye cataract senile
Certain diseases are, predominant in certain ages
For e.g. Measles , febrile fits in children
Parkinson’s disease in old age

Sex.
Boys : Bladder urination invol. Night boys in
Girls. Head pain school girls
Females. Eyes cataract women in
Certain diseases are predominant in females [ e.g. ; Chole lithiasis in females ] and some in males[ e.g.; renal stones in males]

Religion
Diseases invariably seen in relation with religious and cultural customs are to be noted e.g.; Ca Penis Rare in Jews and Muslims

Marital status
Late marriages and null parity pre dispose to Ca breast
Early marriage and frequent deliveries pre dispose to Ca cervix
In materia medica there are medicines for complaints related to late marriages
and related problems e.g.; conium Mac.

Occupation:
There are occupational diseases such as pneumoconiosis and other respiratory problems are more in various industries

E.g. For rubrics – Respn. Asthmatic miner’s asthma

II.Presenting complaints.
The presenting complaint is the complaint which may the patient come to the doctor. Note down the complaints in fresh lines with adequate space in between the symptoms. Go back over what has been presented to clarify meaning of each symptoms. Inquiry is made into the following line to complete the symptoms
a. Duration of the complaint- Suspect the patient who can remember every minute details of his illness as hypochondriacal.
b. Onset of the complaint- Note whether the complaint is of sudden or gradual onset.
Rubric — Gen. Pain appears suddenly
c. Prodrome- Ask for any definite prodrome before the onset of complaints especially in cases where there is a definite exciting cause. Certain medicines in our materia medica such as belladonna, aconite,etc are having a sudden and violent onset of their complaint where as certain medicines such as arsenic. Alb, gelsimium, etc are having a slow development of their illness.
d. Sequence- Ask for any paroxysmal appearance or alternation of symptoms .Note down the exact sequence of appearance of symptoms
Rubric- Vision dim headache before
e. Location- Ask the patient to locate with his hand the exact area involved. Observe whether the patient is showing the area of affection by the whole hand or with the tip of a finger( Rubric- Gen. Pain small spots). If there is any radiation or extension of pain that also should be noted down.
Rubric – Back pain extending to thigh
f. Sensation- Note the exact sensation associated with the complaint
Rubrics- Throat lump sensation
Abdomen pain burning
g. Modalities- Includes causation ( exciting or maintainig factors ) , Aggravation and factors which ameliorate the condition. In general modalities regarding things such as heat and cold, weather changes, activity or rest, position, rubbing or pressure. Etc. are to be noted.
h. Concomitants- These are the unreasonable attendants of the chief complaint and are having great prescribing value. It can be
1. Mental plane- eg- restlessness with pain
2. Physical plane – eg; Perspiration with pain
i. Discharges- In cases with discharges look for
1. Nature of discharge – Serous, bloody, et
2. Color of the discharge- Yellow, white, etc
3. Odor- offensive, cadaverous, etc
4. Consistency- Thin, watery, etc

III.History of presenting complaints.
Evolution of present pathological state of the patient, from the etiology behind, with exact sequence of appearance of current symptoms. Was there any major event in the patient’s life at about the appearance of symptoms?
Any mental or emotional shock such as grief, major financial losses, separation from loved ones, identity crisis, etc.
Any major illness, which might have affected the overall health of the patient, e.g.; prolonged infectious diseases, venereal diseases, etc.
Rubrics related:
Aetiology:
Generalities measles after
Male swelling testes mumps from
Diagnosis:
Gen. Paralysis apoplectic
Nature of the disease:
Rectum constipation chronic
Throat inflammation tonsils recurrent
Eyes inflammation acute
Extension and alternation
Gen. Paralysis ext. upwards
Resp. asthmatic alt. With eruption
Complaints after whooping cough- Pertusin , Drosera
Complaints after typhoid- Typhoidinum
After effects of fright- Opium

IV. History of previous illness
Ask for the previous illness from childhood down to the present, chronologically, which ages at which attack appeared , with its nature, symptom., duration, severity and sequence. It is very important In finding the miasmatic background of the patient.
H/o any surgical intervention, exposure to radiation, etc.
Details of accidents, animal bites, mechanical injuries, mental shock, etc.
H/o any infections, tumors, skin eruptions, etc

Past history may give clue about
a. Etiology. Resp. Asthmatic eruption after suppressed
b. Diagnosis.
Cardiac complaints and joint affections in a patient with a history
of recurrent tonsillitis.
c. Development of the disease
Surgically or mechanically corrected disease in the past history could be considered as presenting complaint in the concept that they would have been present there if surgical intervention has been made. E.g. Are surgically treated hernia, fibroids, hemorrhoids, etc.
d. Miasm
Gen. Sycosis
Gen. Syphilis
H/o Rheumatic fever- Streptococcin
H/o Recurrent boils – Staphylococcin
H/o injury, spinal- Hypericum
After effects of strong sense of injustice- staphysagria
Excessive intake of Iron- Pulsatilla
Prolonged drugging with quinine- Nat.mur
In excessive drugging- Potency of same drug
E.g., Turpentine- terebinthinum
Sulphur fumes- Sulphur potency
After effects of anesthesia- Chloroform (with liver complaints)

V.FAMILY HISTORY
Helps in deciding the miasmatic background.
Helps in tracing consanguinity
Any similar diseases in the family members
Ask about any miasmatic disease in the family including parents, grand parents, and siblings with paternal and maternal relations.
E.g. T.b, Diabetes, Hypertension, eczema, mental diseases, congenital abnormalities, convulsions, etc.
Pre-disposition and tendency to disease
Individual peculiarities of all the relatives, their habits such as alcoholism.
Ask about any deaths- Its cause, age of the deceased, age of the patient at that time, and its impact on the patient.
Diseases of the mother during pregnancy and delivery. Infectious diseases such as rubella, diabetes, hypertension, etc
Nature of deliveries ,any H/o birth asphyxia- relevant in case of mental retardation, epilepsy, etc
Tracing out these details will create a feeling in the patient that doctor wants to know all about them and is deeply interested in the case

VI. PERSONAL HISTORY

1.      Details about where he is born and brought up- Is there any separation from the mentally attached places or persons?

2.      Appearance of different milestones such as dentition, walking, Talking etc

3.      Details of breast-feeding. ask for any early weaning

4.      Socioeconomic status, level of education and any reason for termination of study , occupation- any frequent change of jobs or, job satisfaction social and domestic relations, in the office family,

5.      Marital status, Age of marriage, No. of children, Any frequent deliveries, nature of deliveries whether normal, instrumental, or Cesarean, any abortions, stillbirths, Puerperal infections, etc .

6.      Habits- smoking, betel chewing, alcoholism, tea, coffee, any other drugs

7.      Any extra marital relations.

8.      Place of living- whether in damp, hilly, near the sea, etc.

9.      Interests and hobbies

10.  Ask about one typical day of the patient.

Rubrics related
Resp. Difficult mountains in
Gen, stone cutters
Resp. asthmatic miner’s asthma
Rectum. Constipation sedentary habits from
Resp. asthmatic drunkards
Head pain tobacco smoking from
Mind talking slow learning to
Extre. Walk late learning to
Gen. Development arrested
Marriage-
Mind. Marriage idea of marriage seems unendurable
Genit. Female desire increased in widows

VII. TREATMENT HISTORY
Details of treatment through out the life of the patient, what medicine have been taken with the effects produced . Look for any suppressions or masking of the symptoms. Details of vaccination and its effects on the patient.
Related rubrics.
Chest inflammations lungs abuse of aconite after
Gen. irritability when too much medicines have produced……
Fever changing paroxysm after homoeopathic potencies
Rectum diarrhea vaccination after
Gen. vaccination
Vaccination for rabid dog bite- Hydrophobinum
.
VIII.REGIONALS
Includes the complaints as well as characteristic symptoms related to different organs and systems arranged in a schematic manner from head to foot including skin.

IX. Sleep.
a. Position of the body, head, and extremities during sleep,
b. What the patient is doing during sleep- laughs, starts, shrieks, weeps, is afraid, grind his teeth, keeps eyes/ mouth open, snoring, somnambulism , dribbling of saliva,
c. Quality of sleep- hours and causes of waking, sleepiness, sleeplessness- at what time, difficulty in falling asleep, sleepless waking after,
d. Covering during sleep- of whole body, or parts
e. All about dreams- common dreams of the patient
f. General </ > before, during, after sleep

XIII. Pathology which applies to the patient as a whole
Tendency to tumors, cyst, warts.
Individual and family tendencies to certain diseases
XIV. Ailments from.
Mental plane- Emotions, suppressions
Physical plane- from exposure to cold, wet, sun
From mechanical conditions – injuries, over eating, etc
XV. Overall quality of energy available to function daily
XVI. Sensorium.
Vertigo with its modifications if any
Giddiness

XVII. General modalities
1. Time
Ask for at what time of the day in 24 hours the patient is getting aggravated or ameliorated such as morning, evening, 3AM,3PM, etc. Whether there is any periodicity in appearance such as moon phases, weekly, etc
Rubrics- Gen. Periodicity
Gen. Moon phases- new moon<
2. Meteorological.
a. Heat/ cold
b. Season – summer, winter, and rainy
c. Weather- change of weather, cloudy weather, thunder Storm, open air, clear weather, etc
Rubrics
Gen. Cloudy weather
Gen. Storms
3.Touch- hard or light, pressure, rubbing
Rubrics
Gen. Rubbing amel.
4. Position
Usual positions of aggravations and ameliorations, standing , sitting, lying head high/ low
Rubrics
Gen. Lying sides right agg.
5. Rest or motion
Exertion, walking, car and seasickness. Jar, stepping
Gen. Motion continued amel.
Gen. Riding
Odor, light, etc
6. Discharges
Gen. Agg. Or amel. From discharges if any
XVIII. Mind
a. will – Love , hates, emotions, obstinacy contradiction, Loquacity
b. Understanding- delusion, delirium, hallucinations , time Sense
c. Intellect- Memory, concentration, mistakes – talking , Writing, reading, etc
The symptoms can be elicited in following headings
1.Symptoms relating to the instinct of self preservation- Death, suicide, etc 2.Ailments from grief, vexation, mortification, indignation, anger, bad news, disappointed love
3.Fear, anxiety, anguish.
4.Irritability, anger, violence, impatience, hastiness
5.Sadness, weeping, despair, effect of consolation
6.Other features like jealousy, absent-mindedness, concentration, mania

Instructions in tracing out mental symptoms

1.      Mode of narration of complaint-

2.      His attitude towards illness

3.      How the patient talk?- The rate and quantity of speech. In maniac patient the speech is usually fast and in depressive patients it is slow , patient may pause a long time before replying t questions or may give short answers as also in the case of shyness and low intelligence

4.      Look for any neologisms- private words invented by the patient

5.      Any rapid shift from one topic to another- Flight of ideas or general diffuseness and lack of logical thread may indicate the thought disorder characteristic of schizophrenia

6.      Accompaniments to the suffering- the state of mind that is produced during pain or suffering is often the state of mind of the patient in an uncompensated form

7.      Interests and hobbies- what would you enjoy doing the most? Why?

8.      Patients nature as a child- how he was as a child?

9.      Reactions in life situations- How he reacted in times of stress and Strain in his life

10.  What are the qualities in others and in yourself that you cannot Understand or tolerate.When are you angry with yourself?

11.  Person’s occupation and area of work.

12.  Whether he has chosen himself or circumstances made him to Choose it. How does he behave in his area of work?, Any change of job and reason for that

13.  The situations that the patient has created in his life E.g.; dominating

14.  How do you stand waiting?

15.  How rapidly do you walk, eat, talk, write?

16.  In time of depression how do you look at death? Have you considered any way which you may end your life?

17.  Tell all about over conscientiousness and over scrupulousness about trifles

18.  What are the greatest grieves or joys you have had in life.?

19.  What effect has consolation on you?

20.  On what occasions do you feel frightened or anxious?[ putting examples]. Have you noticed any change in your body and mind when you are feeling anxious? Like palpitation, pains, Thoughts of fainting , losing control or going mad

21.  Interview with friends and relatives

22.  The best technique is to watch what happens spontaneously. Then the other techniques are used only when you reach a dead end and do not know how to proceed further

23.  Any obsessional phenomena-any thoughts keep coming in your mind even though you try hard not to have them. Do you have to keep checking activities that you know you have really completed?

24.  Delusions, illusions, and hallucination- do not ask direct questions but observe from the talks and gestures

25.  Orintation of place, person and time

Dr. Pierre Schmidt is of opinion that mental symptoms should not be asked at the end of case taking because by that time the patient is exhausted and is not able to give out his innermost feelings clearly. Dr. Borland used to say that the best time to ask such questions is when you are examining the patient physically. Physical touch seems to bring the patient closer to the doctor mentally and emotionally.

IX. PHYSICAL EXAMINATIONS
IX.LAB. INVESTIGATIONS
X. DIAGNOSIS WITH D/D
XI. ANALYSIS OF SYMPTOMS
XII. EVALUATION OF SYMPTOMS
Evaluation of symptom implies the principles of grading or ranking of different kinds of symptoms in order of priority, which are to be matched with the drug symptoms in order to cover the characteristic totality in a natural disease condition with that of drug disease. Proper evaluation of symptom is the most important step next to case taking in Homoeopathy.In evaluation of case the value of symptom must be taken in to consideration on several points. Basically symptoms are ranked according to their intensity, how deeply they reach in to the organism ( mental will & emotional symptoms are considered most important ) and according to their degree of peculiarity.

XIII. MIASMATIC EXPRESSION
XIV. REPERTORIAL TOTALITY
XV. IMAGE OF THE PATIENT
Acute, chronic, constitutional, intercurrent
XVI. MANAGEMENT OF THE CASE
General
Medicinal
XVII. OBSERVATION AND FOLLOW UP
Date, basis of selection, prescription, observation
XVIII. ADVICE ON DISCHARGE

References:
1. Organon of medicine by Samuel Hahnemann – B.K.Sarkar
2. Essentials of repetorisation- S.K.Tiwari
3. Kents lectures on Homoeopathic philosophy
4. Genius of Homoeopathy- Stuartclose
5. Principles and art of cure in Homoeopathy- H.A.Robert
6. A brief study course on Homoeopathy- Elizabeth Wright.
7. Logic of Repertories- Castro
8. Writings on Homoeopathy- Kanjilal
9. Hutchison’s Clinical Methods
10.The art of case taking- Pierrie Schmidt
11.The art of interrogation – Pierrie Schmidt
12.An introduction to Principles of repertory and repertorization- Muneer Ahmed
13.Spirit of Homoeopathy-Rajan Sankaran
14.Science of Homoeopathy- George Widhulkas
15.Principles and practice of Homoeopathy- Dhawale
16.Significance of past history in Homoeopathic prescribing-Foubister
17.Manual of Psychiatry- J.P.S. Bakshi
18.Dr.K.B.Rameshan -Principal in charge and professor in Department of Case taking and repertorisation, GHMC Calicut.
19. 20.Text Book of Repertory- Niranjan Mohanthy
21.Case Taking, Case receiving and recording – Niranjan Mohanthy.
22.Art of case taking and practical repertorisation- R.P.Patel
23.’Case taking a developmental approach’ – Seminar paper presented by Mansoor Ali