Case Taking

A useful article about Case Taking.Full details about Case Taking

Introduction

The foremost step towards making a good prescription is a well
taken case. Hahnemann writes

“If the physician clearly perceives what is to be cured
in disease, that is to say, in every individual case of disease
(knowledge of disease, indications), if he clearly perceives
what is curative in medicines, that is to say in each individuals
medicine (knowledge of medical powers), and if he knows
how to adapt, according to clearly defined principles, what is
curative in medicines to what he has discovered to be undoubtedly
morbid in the patient, so that the recovery must ensure—to
adapt it, as well in respect to the suitability of the medicine
most appropriate according to its mode of action to the case before
him (choice of the remedy, the medicine indicated), as also in
respect to the exact mode of preparation and quantity of it required
( proper dose ), and the proper period for repeating the dose;-if,
finally, he knows the obstacles to recovery in each case and is
aware how to remove them, so that the restoration may be permanent:
then he understands how to treat judiciously & rationally,
and he is a true practitioner of the healing art”……………………..
Para –3 of Organon of Medicine

Case taking is an art on which the success or failure depends.
A proper case taking is essential for the success process of the
study of the Repertory and repertorization. Further, the art of
the physician in taking the case must so record it that we may
glean from this record those elements that may be translated into
the rubrics of the repertory. However, it is impossible to secure
from the patient a clear-cut picture of his difficulties, in spite
of the best art the physician may exercise.

Talking to the patients and obtaining their health histories
are usually the first and often the most important parts of the
health case process.

Approach to the Patient

The physician should approach his patients with humility and
gratitude, with confidence and pride in the responsibility which
will be his for the remainder of his life. It is all a matter
of communication between patient and physician. It is no exaggeration
to say that even facial expression, tone of voice and manner of
movement can affect the ability to elicit the patient’s
story and to lead him back to health. For it is in such outward
signs that we display those attitudes of mind – impatience, boredom,
embarrassment, disbelief and reproach – which act as barrier to
communication with others. In the presence of his patients, the
physician must master his emotions, clear his mind of distracting
thoughts and avoid all appearances of haste. His manner should
be alert and attentive yet gentle and sympathetic. Without these
qualities, he will neither obtain the facts needed for the diagnosis
nor effectively convey the advice essential to the patient.

The Disease…

Disease is a departure from health and is manifested in an individual
during life by symptoms. These symptoms are as under:

Subjective Symptoms are those symptoms
that are recognizable only by the patient and present no external
indications such as pain, itching or a feeling of chilliness etc.
Philosophically Subjective reality that exists in the mind only!

Objective Symptoms are those that can
be detected by observer e.g. abdominal enlargement or dullness
on percussion. Philosophically objective reality is that which
can be demonstrated by means of tangible or outward signs, good
deal of pain.

The word symptom is used in two senses. Sometime it used in
a general sense to indicate all the subjective & objective
evidence of a disease; but more usually it is employed in a narrow
sense, as synonymous with subjective symptoms. Objective symptoms
are usually spoken of as signs; and those objective symptoms,
which are made out by physical examination, are known as physical
signs .

Just as the value and significance of physical signs depend
on the skill and experience of the physician who observes them,
so the significance of subjective symptoms has to be weighed and
considered in relation to the character and constitution of the
patient who complains of them. Thus a certain symptom may appear
trivial and unimportant to a patient of strong character not addicted
to introspection, although serious disease may be present; whereas
in women with a susceptible nervous system every subjective symptom,
however slight, may cause great anxiety, exaggeration, and even
real suffering. Sub-mammary pain, for instance, in the first might
indicate aneurysm; in the second, hysteria.

General (or constitutional) symptoms
are those, which relate to the whole body, such as debility or
pyrexia.

Hahnemann writes (Para 71 Organon of Medicine) “As it
is now no longer a matter of doubt that the diseases of mankind
consist merely of groups of certain symptoms and of mankind and
transformed into health by medicinal substances but only by such
as are capable of artificially producing morbid symptoms (and
such is the process in all genuine cures), hence the operation
of curing is comprised in the following points”:

• How is the physician to ascertain what is necessary
to be known in order to cure the disease? (Case Taking)

• How is he to gain knowledge of the instruments adapted
for the cure of the natural disease, the pathogenetic powers of
the medicines?

• What is the most suitable method of employing these artificial
morbific agents (medicines) for the cure of natural disease?

In case taking, our objective is, first, to elicit all the data
of the case; and, secondly, by reasoning based on those data to
arrive at its Diagnosis, Prognosis and Treatment. It will be found
in actual practice that everything turns on the diagnosis; this
is our first and principal object; the prognosis and treatment
follow from this.

The investigation of a case consists of three parts:

• The Interrogation of the Patient

• The Physical Examination

• The further investigation by Special Ancillary Methods
(e.g., Radiology, Clinical Pathology), where necessary

A. Interrogation of the Patient: By interrogating the
patient the objective is to obtain the following information:

• What is his/her chief or cardinal symptom?

• The facts concerning the present illness,

• The patient’s previous history,

• The patient’s personal history, and

• His/her family history

Throughout the interrogation of the patient it is well to follow
three general rules :

1. Avoid putting what barristers call “leading
questions”
i.e., questions that suggest their own
answer: e.g., “Have you had a pain in the back?” suggests
an obvious answer to the patient. It might be put thus: "
Have you had any pain, and if so, where?” The patient should
be encouraged to tell his own story, without interruption. Moreover,
the very words he uses should be recorded between inverted commas,
and on no account should his words be translated into scientific
terms. Some say that leading questions are permissible when the
patient is very ignorant and stupid, but these are the very cases
in which leading questions should be specially avoided. The only
legitimate way of putting a leading question is in an alternative
form—e.g., “Have you suffered from diarrhea or constipation?”
Time, patience and tact are necessary to elicit the true facts
of the case, without irrelevant detail. Our object is to learn
what the patient feels and knows, not what he thinks of his disease;
and our patience is often sorely tried by a long story of his
own or his previous doctors’ views on his case. Our record should
be comprehensive, including all-important data, negative as well
as positive, yet concise i.e., excluding irrelevant facts. Only
experience and knowledge of medicine can teach us what is or is
not relevant. The beginner should strive after completeness rather
than conciseness.

2. A chronological order should always be adopted,
both in eliciting and in recording the facts. Nothing is more
wearisome than to wade through a mass of verbiage, which mixes
up dates. Dates should be recorded always in the same terms. It
is very common, for instance, to read in students’ reports that
“breathlessness began in the year 1952", "palpitation
started when the patient was aged forty," " edema came
on two years ago."

3. Always adopt a kindly and sympathetic manner.
Not only is it our bounden duty to be considerate and patient
with those who suffer, but by entering into the spirit of the
patient’s sufferings we can often get at more important facts,
and a truer narration of them, than can one whose harsh or abrupt
manner causes the patient to shrink up like an oyster into its
shell. Put your question s in as simple and non-technical a form
as possible, and be sure that the patient attaches the same meaning
to the words as you do. Much will depend on the tact of the physician,
and two very good rules may here be added—viz., Never enquire
concerning a family history of a lethal illness such as cancer
before a patient whose illness is likely to be of that nature;
Never put questions bearing on venereal disease before the husband
or wife of the patient.

a. The Chief or Cardinal Symptom : The first
question to ask a patient should always be the same "What
do you complain of?" Special attention should be paid to
the main symptom for which the patient seeks advice or is admitted
to hospital, because it is this symptom, which guides most of
our subsequent inquiries. It should always, as far as possible,
be recorded in the patient’ s own words. The best way to avoid
error is to verify your observations by repeating your examination.

b. The History of the Present Illness must
be/taken and recorded with care. Some patients come out at once
with their story; others remain silent. The former must not be
interrupted except to steer them away from irrelevancy. The latter
should be gently encouraged rather than questioned. In other words,
the patient’s history should whenever possible be received,
not taken.

Most patients expect the doctor to make the first move . After
a few words to put the patient at ease, he must find out why the
patient has come. The conventional opening question “What
do you complain of?” is not always suitable. Some patients
have no real symptoms but feel obliged to mention a minor discomfort
in answer to this question when in fact they have come with a
problem rather than a pain. The more sympathetic question, “What
can I do to help you?” sometimes brings a more revealing
answer. However, more than one approach may have to be made before
the appropriate response is obtained; a list of suggested alternative
is given as under: Whether the patient is presenting with a symptom
or a problem, this should be recorded in the patient’s own
words, along with note of its duration. If the patient’s
own words consist of a diagnosis rather than a symptom, he must
be asked to indicate how this condition affects him. The symptoms
and not the “diagnosis” are then recorded e.g. Chest
pain: One week, Cough: 2 moths etc.

Questionnaire

• What do you feel wrong with yourself?

• In what way do you feel ill?

• What can I do to help you?

• Tell me why you wanted to have homoeopathic treatment?

When the patient is finished his story and answered “No”
to the question: “Have you any other symptom
at all?”, he may then be asked leading questions to ensure
that no symptom has been forgotten.

Onset (record for each symptom in chronological order)

• When did you (symptom) first start?

• Were you perfectly well before then?

• Have you ever had anything like this before?

• Did your (symptom) come suddenly one day or gradually
or periodically?

• What were you doing when it came on? (if onset is sudden)

Development (record for each symptom in chronological order)

• What has happened to your (symptom) since then?

• Coming & going? (record frequency, duration &
relationship if any to physiological or environmental factors)

Getting worse or better? (Record whether the change has been
gradual; if not, then when it occurred and whether related to
physiological or environmental factors. Description (pain given
here as an example)

• Show me where you feel pain?

• Does it move anywhere?

• What kind of pain is it? (aching, stabbing, throbbing,
gripping etc)

• How bad is it? Does it make you stop what you are doing?

• How often do you get it? (record whether continues or
number of times per day,
week, month or year)

• How long does it last?

• Does it come at any special time?

• Does anything bring it on or make it worse?

• Does anything relieve it? What do you do when it comes
out?

• Do you feel anything else wrong at the same time?

It cannot too strongly be emphasized that in many diseases a
full and accurate history of the illness may be the only method
of arriving at a diagnosis, for physical signs may be absent or
in abeyance (e.g., in angina pectoris). Taking an average, it
is fair to compute that of the in formation on which a diagnosis
is ultimately founded, at least 50 per cent comes from an accurate
history, and rather less than 50 per cent, from the physical examination
and subsequent special investigations. The history should then
reveal:

i. The mode of onset, whether sudden or gradual,

ii. What the patient was doing at the time, and whether he attributed
the onset to any cause. In many cases it is necessary to enquire
into

iii. Whether the symptom is localized or widespread,

iv. Does it radiate to other areas; also

v. The duration of the symptom,

vi. Whether it ended suddenly or gradually,

vii. Its severity,

viii. Whether it has occurred since, and if so, how many times,
and is it getting more or less severe,

ix. What intervals of freedom have occurred, when the patient
has been entirely free of the symptom,

x. Have other symptoms occurred in association with this chief
symptom, and if so, what are they,

xi. What does the patient do during the time of the symptom to
relieve it,

xii. Has the patient found any measures of avail to ward off attacks,
e.g., drugs, diet, etc. In many cases, e.g., in juvenile and unconscious
persons, the history has to be elicited from near relatives or
friends. It is useful also to know whether the patient has recently
been, or is now, under medical care, not only because the symptoms
may have been modified by treatment, but also because one of the
most important ethical principles of the medical profession may
be involved. In all these enquiries the above stated general rules
given above apply.

c. The Previous History of the patient bears
largely on the etiology, or causation, of his illness, and deals
with any illnesses the patient may have had. Note in chronological
order all ailments from which the patient has suffered prior to
the present one, with the dates of their occurrence and their
duration: e.g., contagious diseases of childhood; and especially
previous operations or serious illnesses. If the illnesses have
been at all obscure, it is desirable to add a few of the leading
symptoms to prove the nature of the alleged attacks, and in such
instances inverted commas should be freely used. For instance
“rheumatism” is vague terms which may mean any disease
attended by pains in the limbs, such as are due to alcoholism,
syphilis, tabes dorsalis or neurasthenia. The subject of syphilis
should always be approached with delicacy in the case of women.
Indirect information may often be gained by enquiring for prolonged
sore throat, followed by loss of hair, enlarged glands, skin rashes
, etc. In married women, a series of stillbirths, or children
born with eruptions or snuffles, may have the same significance.

Questionnaire

• Have you had any serious illness in the past?

• How did it affect you?

• Any operation or bad injuries?

• Any stillbirth, miscarriage or problem in pregnancy?

• Have you ever been to hospital?

• Have you missed time from work because of illness?

• Have you ever visited doctor before?

• Have you ever had (here list illness possibly relevant
to present complaint)

d. The Personal History must be enquired into
such as:

i. Present and previous occupations;

ii. Previous residence abroad;

iii. The home conditions;

iv. Habits as to alcohol and tobacco and whether alcohol (e.g.,
wine, beer or spirits) is taken between or with meals, because
more harm is done by alcohol before meals (especially cocktails)
than many times the same quantity taken with meals;

v. The appetite;

vi. The state of the digestion and the bowels;

vii. The weight, and whether this is constant, being gained or
lost;

viii. The general state of the nervous system, e.g., depression,
excitability, nervousness;

ix. The orientation of the patient to his (or her) work and to
home life, and whether there are any special anxieties attached
to these;

x. The amount and quality of sleep;

xi. In women, the previous state of the catamenia, and the number
of pregnancies, miscarriages or stillbirths, should be noted.

e. The Family History may, like the previous
history, have a casual relationship to the patient’s illness.
The age and state of health if living, age and cause of death
if dead, of near relations, should always be noted: i.e., father
and mother, brothers and sisters, sons and daughters, also of
husband or wife. Enquiry should also be made as to whether any
members of the family (parents, grandparents, brothers, sisters,
uncles, aunts or cousins) have suffered from tuberculosis, cancer,
acute rheumatism, gout, nervous disease, asthma, heart disease,
apoplexy, and especially those diseases to which the patient himself
seems liable.

Questionnaire

• Are you married?

• Is your wife/husband well?

• Do you have children? (record age & sex)

• Have they ever been seriously ill (record details)

• Have you lost any children? (record age & cause of
death)

• Do you have brothers & sisters (record age & sex)

• Have they ever been seriously ill? (record details)

• Have you lost any brothers or sisters? (record age &
cause of death)

• Are both of your parents living? (if not, give age &
cause of death)

• Have they ever been seriously ill? (record details)

• Do you know of any one in the family with symptoms like
yours?

• Do you know of any disease affecting more than one member
of your family?

f. Social History, question asked under this
heading are designed to uncover anything in the patient’s
personal life, relevant to either the cause or management of his
ill health. We need therefore, to know about his work, hobbies,
habits, environment at home, visits abroad, domestic and marital
life any potential source of mental illness.

Questionnaire

• Are you working?

• What exactly do you do? (record hours, physical activity,
potential hazards, traveling)

• How long you have done this job?

• What jobs have you done before, starting when you left
school? (record as above)

• What do you do in your spare time? (hobbies, sports etc.)

• Are your mealtimes regulars?

• When is your main meal?

• Do you or did you smoke? (record duration, number of cigarettes/cigars/pipes
per day)

• Do you or did you take alcohol? (record type & amount)

• Do you or did you take drugs of any kind? (record type
& amount)

• Have you been abroad? (record where & when)

• Tell me about your home? (rooms, stairs, toilet facilities,
state of repair)

• Who is living in the same house?

• Have any been ill recently?

• Do you have animals at home?

• Have you had any recent worries or stresses?

B. Physical Examination:

1. Here, again, having learned by interrogation
our patient’s chief complaint, we should ask ourselves, is there
any striking or predominant sign or appearance? The importance
of inspecting our patient cannot be overestimated. In these days
of scientific instruments we are too likely to forget to use our
own faculties. By simply using our eyes many important data may
be learned besides the color of the skin, the condition of the
teeth and gums, the general nutrition, the attitude or decubitus,
and the facial expression. For instance, the manner in which a
patient answers questions is often the first clue to anxiety,
and a peculiar mode of speech is one of the pathognomonic signs
of general paralysis of the insane, disseminated sclerosis and
other diseases. Moreover, with experience we can by this means
form a conclusion as to the kind of patient we have to deal with.
Again, never be in a hurry; only by taking time can we fully appreciate
all the points presented to us. This habit of “observing”
the patient is only developed by long practice; it will never
be developed if the young physician allows himself to be infected
by the hurry of modern times.

2. It is important always to commence examination
with that ORGAN TO WHICH THE SYMPTOMS ARE MAINLY REFERABLE. Some
teachers direct their pupils, to examine and report on the physiological
systems always in the same order (first the heart, then the lungs,
then the digestive system and so forth), whatever, may be the
illness.

But such a course has three objections:

i. The student goes about his work in a mechanical
fashion;

ii. If the patient suffers from some serious
disorder, such as peritonitis, he may be exhausted by a complete
investigation of the chest and other parts during the acute illness;
and

iii. Often it is a waste of time to examine all
the organs with equal thoroughness. The same educational advantages
and experience can be obtained by the other method, and in th
at way we come to the most important facts first.

3. In all cases EVERY ORGAN IN THE BODY SHOULD
BE CAREFULLY EXAMINED; for although we may find in one physiological
system sufficient mischief to account for the patient’s
symptoms, the other organs may reveal changes, which considerably
modify treatment, prognosis & even diagnosis. Whatever order
is adapted; the student should not wander from organ to organ,
but examine each physiological system thoroughly before proceeding
to the next.

It is best to get in to the habit of adopting some such order
of physical examination as the following: first, note the general
conditions; second, examine the organ chiefly affected; third
, other organs in the following order: Thorax (heart and lungs),
Abdomen (alimentary canal, liver, spleen and genito-urinary system),
Head and Limbs (nervous and motor systems).

The examination should always be carried out gently and without
undue exposure. In serious cases, especially when the heart or
lungs are involved, it is often well to postpone a thorough examination
of some organs, so as not to risk harming the patient by exposing
or fatiguing him. On the other hand, the young physician should
never allow modesty to prevent his making a through decision.
This rule is more necessary in sensitive patients, but a little
firmness, tact, and a courteous demeanor will generally enable
him to perform what is a duty both to his patient and to himself.

After completing the above schedule, we have to individualize
remedies and patient. The concept of individualization as reflected
in the totality of the symptoms furnishes the only sound basis
for selection of remedy in Homoeopathy practice. Individualization
is another name for a process of synthesis done after the analysis
of an accurate and complete data recorded after observation and
examination of the patient.

As individuality of each man is unique, his reactions to environment
and other factors also vary from man to man. In homoeopathic language
such a concept of a whole and an individual man that is ill, is
expressed through “totality of symptoms” which is
indicative of the deviation from the total state of health.

In homoeopathy the entire examination of a patient is conducted
with a view to discovering not only the general or common features
of the case by which it is classified diagnostically and pathologically,
but also the special and particular symptoms which differentiate
the case from others of the same general class. It recognizes
the fact that no two cases or patients, even with the same disease
are exactly alike. In actual practice the “differences”
are very often the deciding factor in the choice of the remedy.

Homeopathically each symptom of the patient’s sickness
has to be modified by the following factors before going for Repertorisation
/ Simllimum:

• Laterality or sides

• Time-hour

• Modifications-conditions, circumstances

• Extension

• Location

• Character or kind of sensation

In Organon para 83-104, Hahnemann provides the complete instructions
for “Case taking”. ACCORDING TO THE MASTERS, MOST
HOMOEOPATHIC DOCTORS MAKE THE THREE MISTAKES IN CASE TAKING

• Interruption

• Yes or No answers

• Confirming the remedy you want (Pet remedy)

Hahnemann writes

“…..he then makes a note of what he himself observes
in the patient and ascertains how much of that peculiar to the
patient in his healthy state” (para 90 of Organon).

How to Diagnose?

It is always important that how the data elicited may be utilized
in order to arrive at Diagnosis. An attempt is made to find a
single diagnosis which will account for most or all the facts
of the case. If some facts do not fit the pattern appropriate
to diagnoses, their accuracy must be checked and the original
diagnosis reviewed before two or more separate diagnosis are postulated.
A complete diagnosis would describe the patient’s illness
in terms of the site (Anatomy: where?), nature (Patho-physiology:
what?) and cause (Etiology: why?) of the disease process. In most
instances, however, the physician has to satisfied with a differential
diagnosis which admits to more that a single possible answer to
one or more of these questions. The alternative diagnosis should
be listed in order of probability and reasons given in support
of the one which is preferred.

When considering the differential diagnosis, priority must always
be given to the problems for which the patient sort medical advise.

C. Special Investigations:

About the author

B. S. Sahni

B. S. Sahni

B. S. Sahni

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