An Overview of Case Taking
Definition: Case taking is the process of collecting all the facts about the patient, using various tools like observation, perception, history-taking – given by the patient/attendant, clinical examination etc. in order to find a remedy for the patient – using our knowledge of Homeopathic Materia Medica, Organon of Medicine, and Reparatory.
According to Dr. Stuart Close: “The purpose of homeopathic examination is to bring out the symptoms of the patient in such a way as to permit their comparison with the symptoms of the materia medica for the purpose of selecting the similar or Homeopathic remedy.
Objective of Case-Taking: Collection of all the facts pertaining to the patient, which may help in reaching to the totality of the patient and thereby help in finding the correct similimum. It is also said that a case well taken is a case half cured.
Dr. Samuel Hahnemenn’s guidelines regarding the art of case-taking
Dr. Hahnemann in his ‘Organon of Medicine’, aphorisms 83-104, has given the following instructions regarding the method of case-taking:
$83: This individualizing examination of a case of disease, for which I shall only give in this place general directions, of which the practitioner will bear in mind only what is applicable for each individualizing case, demands of the physician nothing but freedom from prejudice and sound senses, attention to observing and fidelity in tracing the picture of the disease.
$84: The patient details the history of his sufferings; those about him tell what heard him complain, of how he has behaved and what they have noticed in him, the physician sees, hears, and remarks by his other senses what there is of an altered or unusual character about him. He writes down accurately all that the patients and his friends have told him in the very expressions used by them. Keeping silence himself he allows them to say all they have to say, and refrains from interrupting them unless they wander off to other matters. The physician advises them at the beginning of the examination to speak slowly, in order that he may take down in writing the important parts of what the speakers say.
$85: He begins a fresh line with every new circumstance mentioned by the patient or his friends, so that the symptoms shall be all arranged separately one below the other. He can thus add to any one, that may at first have been related in too vague a manner, but subsequently more explicitly explained.
$86: When the narrators have finished what they would say of their own accord, the physician then reverts to each particular symptom and elicits more precise information respecting it in the following manner; he reads over the symptoms as they were related to him one by one, and about each of them he inquires for further particulars; e.g., at what period did his symptom occur? What is previous to taking the medicine he had hitherto been using? Whilst taking the medicine? Or only some days after leaving off the medicine? What kind of pain, what sensation exactly, was it that occurred on the spot? What was the precise spot? Did the pain occur in fits and by itself, at various times? How long did it last? At what time of the day or night, and in what position of the body was it worst, or ceased entirely? What was the exact nature of this or that event or circumstances mentioned-describing in plain words.
$87: And thus the physician obtains more precise information respecting each particular detail, but without ever framing his questions so as to suggest the answer to the patient, so that he will be misled to answer yes or no; else he will be misled to answer in the affirmative or negative something untrue, half true, or not strictly correct, either from indolence or in order to please his interrogator, from which a false picture of the disease and an unsuitable mode of treatment may result.
$88: If in these voluntary details nothing has been mentioned respecting several parts or functions of the body or his mental state, the physician asks what more can he be hold in regard to these parts and these functions, or the state of his disposition or mind; but in doing this he only makes use of general expression, in order that this informants may be obliged to enter into special details concerning them.
$89: When a patient has by these details given of his own accord and in answer to inquiries, furnished the requisite information and traced a tolerably perfect picture of the disease, the physician is at liberty and obliged to ask more precise, more special questions.
What sort of taste has he in his mouth? What kind of food and drink are most relished? What are most repugnant to him? Has each it’s full natural taste, or some other unusual taste? How does he feel after drinking or eating? Has he anything to tell about the head, the limbs, or the abdomen?
$90: When the physician has finished writing down these particulars, he then makes a note of what he himself observes in the patient, and ascertains how much of that was peculiar to the patient in his healthy state.
$91: The symptoms and feelings of the patient during a previous course of medicine do not furnish the pure picture of the disease; but, on the other hand, those symptoms and ailments which he suffered from before the use of medicines or after they have been discontinued for several days, give the true fundamental idea of the original form of the disease, and these especially the physician must take note of. When the disease is of a chronic character, and the patient has been taking medicine up to the time he is seen, the physician may with advantage leave him some days quite without medicine, or in the meantime administer something of an unmedicinal nature and defer to a subsequent period the more precise scrutiny of the morbid symptoms, in order to be able to grasp in their purity the permanent uncontaminated symptoms of the old affection and to form a faithful picture of the disease.
$92: But if it be a disease of a rapid course, and if its serious character admit of no delay, the physician must content himself with observing the morbid conditions, altered though it may be by medicines, if he cannot ascertain what symptoms were present before the employment of medicine, – in order that he may at least form a just apprehension of the complete picture of the disease in its actual condition, that is to say, of the conjoint malady formed by the medicinal and original disease, which from the use of inappropriate drugs is generally more serious and dangerous than was the original disease, and hence demands prompt and efficient aid, and by thus tracing out the complete picture of the disease he will be enabled to combat it with a suitable homeopathic remedy, so that the patient shall not fall a sacrifice to the injurious drugs he has swallowed.
$93: If the disease has been brought on a short time, or, in the case of a chronic affection, a considerable time previously, by some obvious cause, then the patient-or his friends when questioned privately-will mention it either spontaneously or when carefully interrogated.
$94: When inquiring into the state of chronic diseases, the particular circumstances of the patient with regard to his ordinary occupation, his usual mode of living and diet, his domestic situation, and forth, must be well considered and scrutinized, to ascertain what there is in them that may tend to produce or to manifest disease, in order that by their removal the recovery may be promoted.
$95: In chronic diseases the investigation of the signs of disease above mentioned, and of all others, must be pursued as carefully and circumstantially, as possible, and the unique peculiarities may be attended to, partly because in these diseases these are the most characteristic and least resemble those of acute diseases, and if a cure is tom be affected they cannot be too accurately noted; partly because the patients become so used to their long sufferings that they pay little or no heed to the lesser accessory symptoms, which are often very pregnant with meaning-often very useful in determining the choice of the remedy-and regard them as almost a necessary part of their condition, almost as health, the real meaning of which they have well-nigh forgotten in their sometimes fifteen or twenty years of suffering, and they can scarcely bring themselves to believe that these accessory symptoms, these greater or lesser deviation from the healthy state, can have any connection with the principal malady.
$96: Besides this, the patients themselves differ so much in their dispositions, the some, especially the so-called hypochondriacs and other persons of great sensitiveness and impatient of suffering, portray, their symptoms in too vivid colours and, in order to induce the physician to give them relief, describe their ailments in exaggerated expressions.
$97: Other individuals of an opposite character, however, partly from false modesty, partly from a kind of mildness of disposition or weakness of mind, refrain from mentioning a number of their symptoms, describing them in vague terms, or allege some of them to be of no consequence.
$98: Now, as certainly as we should listen particularly to the patients description of his sufferings and sensations, and attach credence especially to his own expressions wherewith he endeavors to make us understand his ailments-because in the mouth of his friends and attendants they are usually altered and erroneously stated-so certainly on the other hand, in all diseases, but especially in the chronic ones, the investigation of the true, complete picture and its peculiarities demand special circumspection, tact, knowledge of human nature, caution in conducting the inquiry and patience in an imminent degree.
$99: On the whole, the investigation of acute disease, or of such as have existed but a short time, is much the easiest for the physician, because all the phenomena and deviations from the health that has been recently lost are still fresh in the memory of the patients and his friends, still continue to be novel and striking. The physician certainly requires to know everything in such cases also; but he has much less to inquire into; they are for the most part spontaneously detailed on him.
$100: In investigating the totality of the symptoms of epidemic and sporadic diseases it is quite immaterial whether or not something similar has ever appeared in the world before under the same or any other name. The novelty or peculiarity of a disease of that kind makes on difference either in the mode of examining or of treating it, as the physician in any way regard the pure picture of every prevailing disease as if it were something new and unknown and investigate it thoroughly for itself, if he desires to practice medicine in a real and radical manner, never substituting conjuncture for actual observation, never taking for granted that the case of disease before him is already wholly or partially known, but always carefully examining it in all its phases; and this mode of procedure is all the more requisite in such cases, as a careful examination will show that every prevailing disease in many respects a phenomena of a unique character differing vastly from all previous epidemics, to which certain names have been falsely applied-with the exception of those epidemics resulting from a contagious principle that always remain the same, such as small-pox, measles, &c.
$101: It may easily happen that in the first case of an epidemic disease that presents itself to the physician’s notice he does not at once obtain a knowledge of its complete picture, as it is only by a close observation of several cases of every such collective disease that he becomes conversant, with the totality of its signs and symptoms. The carefully observing physician can, however, from the examination of even the first or second patients, often arrives so nearly at the knowledge of the true state as to have in his mind a characteristic portrait of it, and even to succeed in finding a suitable, homeopathically adapted remedy for it.
$102: In the course of writing down the symptoms of several cases of this kind the sketch of the disease becomes even more and more complete, no more spun out and verbose but more significant, and including more of the peculiarities of this collective disease; on the one hand the general symptoms become precisely defined as to their peculiarities and on the other, the more marked and special symptoms which are peculiar but to few diseases and of rarer occurrence, at least in the same combination, become more prominent and constitute what is characteristic of this malady. All those affected with the disease prevailing at a given time have certainly contracted it from one and the same source and hence are suffering from the same disease; but the whole extent of such an epidemic disease and the totality of its symptoms can not be learned from one single patient, but is only to be perfectly deduced and ascertained from the sufferings of several patients of different constitutions.
$103: In the same manner as has here been taught relative to the epidemic disease, which are generally of an acute nature, the miasmatic chronic maladies, which, as I have shown, always remain the same in their essential nature, especially the Psora, must be investigated, as to the whole sphere of symptoms, in a much more minute manner than has ever been done before, for in them also one patient exhibits a portion of their symptoms, a second and third, and so on, present some other symptoms, which also are but a portion of the totality of the symptoms which constitute the entire extent of this malady, so that the whole array of the symptoms belonging to such a miasmatic, chronic disease, and especially to the Psora, can only be ascertained from the observation of very many single patients affected with such a chronic disease and without a complete survey and collective picture of these symptoms, the medicines capable of curing the whole malady homeopathically cannot be discovered; and these medicines are, at the same time, the true remedies of the several patients suffering from such chronic affections.
$104: When the totality of the symptoms that especially mark and distinguish the case of disease or, in other words, when the picture of the disease, whatever be its kind, is once accurately sketched, the most difficult part of the task is accomplished. The physician has then the picture of the disease, especially if it be a chronic one, always before him to guide him in his treatment; he can investigate it in all its parts and can pick out the characteristic symptoms in order to oppose to these, that is to say, to the whole malady itself, a very similar artificial morbific force, in the shape of a homeopathically chosen medicinal substance, selected from the list of all the symptoms of the medicines whose pure effects have been ascertained. And when, during the treatment, he wishes to ascertain what has been the effect of the medicine, and what change has taken place in the patient’s state; at this fresh examination of the patient he only needs to strike out of the list of the symptoms noted down at the first visit those that have been ameliorated, to mark what still remains, and add any new symptoms that may have supervened.
A Broad Scheme of Case Taking
1. History or interrogation of the patient
(a.) Particulars of the patient
(b.) Present complaints
(c.) Personal history
(d.) Past history
(e.) Family history
(f.) Homeopathic generalities
2. Physical examination
3. Provisional diagnosis
4. Special investigation
5. Clinical diagnosis
6. Miasmatic diagnosis
7. Diagnosis of the patient-Individualization
8. Therapeutic diagnosis-by totality of symptoms through the process of evaluation after interpretation and analysis.
Gist of Case-Taking
(Adapted from “A Brief Study Course in Homeopathy” by Dr. Elizabeth Wright.)
I. The patient’s story.
II. Modalities as applied to each of the above symptoms in the following order:
(b.) Prodorme, onset, pace, sequence, duration
(c.) Character, location, laterality, extension and radiation of pain or sensations.
(d.) Concomitants and alterations
(e.) Aggravation or amelioration.
1. Time (hour, day, night, before or after midnight); periodicity; seasons; moon phases.
2. Temperature and weather; chilly or warm blooded usually, chilly or warm blooded in present illness; wet, dry, cold or hot weather changes; snow storm, thunder storm; hot sun, wind, fog, snow; open air, warm room, changes from one to another, stuffy crowded places, draughts, warmth of bed, heat of stove, uncovering.
3. Bathing (hot, cold, or sea), local applications (hot, cold, wet, or dry).
4. Rest or motion (slow, rapid, ascending, or descending, turning in bed, exertion, walking, on first motion, after moving a while, while moving, after moving, car and sea-sickness).
5. Position: standing, sitting (knee-crossed, rising from sitting), stooping (rising from stooping), lying (on painful side, back, right or left side, abdomen, head high or low, rising from lying), leaning head backward, forward, side-wise, closing or opening eyes, any unusual position such as knee-chest.
6. External stimuli: touch (hard or light), pressure, rubbing, constriction (clothing etc.), jar, riding, stepping, light, noise, music, conversation, odours.
7. Eating: in general (before, during, after hot or cold food or drink), swallowing (solids, liquids, empty), acids, fats, salt, salty food, starches, sugar and sweet; green vegetables, milk, eggs, meat, fish, oysters, onions, beer, liquor, wine, coffee, tea, tobacco, drugs etc.
8. Thirst: quantity, frequency, hot, cold, or iced, sours, bitter, etc.
9. Sleep: in general (before, during, on falling asleep, in first sleep, after, on waking)
10. Menses: before, during, after, or suppressed.
11. Sweat: hot or cold, foot sweat, partial or suppressed.
12. Other discharges: bleeding, coryza, diarrhoea, vomiting, urine, emissions, leucorrhoea, etc., suppression of the same.
(f.) Strange, rare, and peculiar symptoms.
III. The patient as a whole: Physical Generals and Mental Generals.
(a.) The constitutional type of the patient.
(b.) Ailments from emotions: Suppressions (emotion discharges such as menses, sweat, leucorrhoea, catarrh, diarrhoea, etc.; eruptions; diseases e.g. malaria, rheumatic fever, syphilis, gonorrhea, etc; of pathology e.g. haemorrhoids, fistulae, ulcers, tonsils, tumors, other surgical conditions etc.); from exposure of cod, wet, hot, sun, etc. from mechanical conditions e.g., overeating, injury, etc.)
(c.) Menses: date of establishment, regularity (early or late), duration, colour, consistency, odour, amount, clots, consistency, aggravation or amelioration before, during, or after (both physically and mentally), menopause (symptoms of).
(d.) Other discharges: cause, colour, consistency, odour, acrid, or bland, symptoms from suppression of, symptoms alternating with; hot or cold, partial discharges as of sweat, laterality, better or worse from discharges (before, during, or after).
(e.) Sleep: better or worse from, position in aggravation after, difficulty in getting to sleep, waking frequently or early, at what hour, somnambulism, talking in sleep, dreams, restless during.
(f.) Restlessness: prostration, weakness, trembling, chill, fever, etc.
(g.) Aggravations and Ameliorations referring to patient as a whole.
(h.) Objective symptoms e.g., redness of orifices, superfluous hair, applying to the patient as a whole.
(i.) Pathology, which applies to the patient as a whole, e.g., tendency to tumors, wens, cysts, polyps, warts, moles-individuals and family tendency to certain disease or weakness of specific organs of tissues (also related to (a.) above and to physician examination), frequency of catching cold.
(a.) Will: loves, hates and emotions (suicidal, loathing of life); lasciviousness, revulsion to sex, sexual perversions; fears; greed, eating, honey, emotionality. Smoking, drinking, drugs; dreams; homicidal tendencies, desire or aversion to company, family, friends; jealousy, suspicion, obstinacy, contrariness, depression, loquacity, impatience, conscientiousness.
(b.) Understanding: delusions, delirium, hallucinations, mental confusions, loss of time sense.
(c.) Intellect: memory, concentration, mistakes in writing and speaking.
IV. Quick review of conditions of every system and organ beginning with head to foot.
V. Past history of the patient.
VI. Family history.
This includes general survey, local examination and general examination.
(A.) General Survey:
(1.) General assessment of illness
(2.) Mental state and intelligence
(3.) Built and state of nutrition
(6.) Facies:- look at the face
(7.) Decubitus:- position of patient in bed
(8.) Colour of skin
(10.) Skin eruptions
(B.) Local Examination:
This is the most important part of physical examination, as a careful local examination will give a definite clue to arrive at a diagnosis. By local examination, we mean examination of the affected region. It should be done using following clinical methods of examination:
(1.) Inspection – looking at the affected part of the body. It should be carried out after complete exposure of the affected part. It should be compared with the corresponding normal appearance, whenever possible.
(2.) Palpation – feeling the affected part by hands. It will not only corroborate the findings seen in inspection but also added information and with trained hands may not require any further examination to come to a diagnosis.
(3.) Percussion – listening to the tapping note of a finger placed over another finger or a percussion hammer.
(4.) Auscultation – listening to the sounds produced within the body with the help of a stethoscope.
(5.) Movements and Measurements – movements of the joint concerned and measurements of the affected part are important in orthopedic cases and cases of nerve injuries and trauma.
(6.) Examination of the Lymph Nodes – helps in clinical diagnosis of many acute and chronic inflammatory conditions and also the nature of any neoplastic growth i.e. whether benign or malignant, and the extent of metastasis.
(B.) General Examination:
It is required to exclude any systemic disease in a patient coming with a localized problem. It is also helpful in finding the real cause of a symptom occurring in a particular organ when the cause of the localized symptoms lies some where else in the body. For e. g; pain in shoulder can be due to pressure on diaphragm by some abdominal pathology.
Attributes for Case Taking
The case record should be analyzed for the following attributes:
(1.) Each of the symptoms must be complete with regard to the sensation, location, modality, and concomitant.
(2.) The symptoms should have a chronological order of development and progress.
(3.) They must be divisible into subjective and objective ones.
(4.) The symptoms must be divisible into generals and particulars.
(5.) Each of the general or particular symptoms must be differentiated as common or uncommon.
(6.) The grade of each symptom must be carefully noted.
(7.) The peculiar combinations, or concomitance, or alteration of certain symptoms, if present, must be clearly noted.
(8.) Environmental, occupational and other exogenous influences on the case must be depicted.
(9.) The past history and the family history of the case should be given due attention.
(10.) The case record should be neat, orderly, comprehensible, and complete in all respects
Homeopathic Case Taking and Pathological Diagnosis
— Views of Dr. Stuart Close
“ The diagnosis of the disease by modern methods is based largely upon physical signs, tests, and reactions, involving the use of many instruments of precision, in which the patient takes no active part, and of which he has knowledge. The selection of the homeopathic remedy on the other hand, is based very largely and sometimes entirely on the phenomena, or deductions drawn from the phenomena, of subjective, conscious experience, perceived only by the patient and stated by him to the examiner. Nearly all of the objective phenomena possessing value from the standpoint of homeopathic therapeutics are of such a character that they require the exercise of only the physical senses and ordinary powers of observation by the patient, his friends, or the physician himself. This distinction should be kept clearly in mind. Examination for the purpose of pathological study and for diagnosis are necessary and important in their several fields; but from the stand point of homeopathic pharmaco-therapeutics, their importance is relative, not absolute. Aside from the physical and organic localization of disease, they furnish comparatively little that is of value to the homeopathic prescriber in his special work of selecting the symptomatically similar medicine.”
“…….In this spirit we may all cooperate for the best interests of our profession and our patients, and agree with Hahnemann in the postulate of the first paragraph of the “Organon”: “The highest and only mission of the physician is to heal the sick.” Every medical specialty is subordinate to that ideal. The work of the homeopathic prescriber, dealing with specifically with the application of medicines to disease according to a definite principle for the purpose of curing such conditions as are amenable to medicines, must ever remain one of the most important of the functions fulfilled by the physician.”
A Note on the “Totality of Symptoms”
–Views of Dr. Stuart Close
“ The totality of the symptoms means, first, the totality of each individual symptom. A single symptom is more than a single fact; it is a fact with its history, its origin, its location, its progress or direction, and its conditions.”
“…….The totality of symptoms means all the symptoms of the case which are capable of being logically combined into a harmonious and consistent whole, having form, coherency, and individuality. Technically, the totality is more than the mere numerical totality of the symptoms. It includes the “concomittance” or form in which the symptoms are grouped.”
“……The “totality” is not, therefore, a mere haphazard, fortuitous jumble of symptoms thrown together without rhyme or reason, any more than a similar haphazard collection of pathogenetic symptoms in a proving constitutes Materia Medica.
The totality means the sum of the aggregates of the symptoms: not mere the numerical aggregates—the entire number of the symptoms as particulars or single symptoms—but their sum total, their organic whole as an individuality. As a machine set up complete and in perfect order is more than a numerical aggregate of its single dissociated parts, so the totality is more than the mere aggregate of its constituent symptoms. It is the idea or plan, which unites them in a special manner to give them its characteristic form. As the parts of a machine cannot be thrown together in any haphazard manner, but each part must be fitted to each other art in a certain definite relation according to a preconceived plan or design—“assembled”, as the mechanics say—so the symptoms of a case must be “assembled” in such a manner that they constitute an identity, an individuality, which may be seen and recognized as we recognize the personality of a friend”
–Guidelines by Dr. Samuel Hahnemann in his “Organon of Medicine”:
$6: The unprejudiced observer—well aware of the futility of the transcendental speculations which can receive on confirmation from experience—be his powers f penetration ever so great takes note of nothing in every individual except the changes in the health of the body and of the mind which can be perceived externally by means of the senses; that is to say, he notes only deviations from the former healthy state of the now diseased individual, which are felt by the patient himself, remarked by those around him and observed by the physician. All these perceptible signs represent the disease as a whole extent; that is, together they form the true and only conceivable portrait of the disease.
$15: The affection of the morbidly deranged, spirit like dynamis that animates our body in the invisible interior, and the totality of the outwardly cognizable symptoms produced by it in the organism and representing the existing malady constitutes a whole; they are one and the same.
$17: Now, as in the cure effected by the removal of the whole of the perceptible signs and symptoms of the disease the internal alteration of the vital force to which the disease is due—consequently the whole of the disease—is at the same time removed, it follows that the physician has only to remove the whole of the symptoms in order, at the same, to abrogate and annihilate the internal change, that is to say, the morbid derangement of the vital force—consequently the totality of the disease, the disease itself.
$18: From the indubitable truth, that besides the totality of the symptoms nothing can be by any means discovered in disease where with they could express their need of aid, it follows undeniably that the sum of all the symptoms in each individual case of disease must be the sole indication, the sole guide to direct us in the choice of a remedy.