Case Taking

1. Case Taking Aphorism 83-104 www.similima.com 1

2. Case taking serves the most essential part in the study of repertory If case taking is imperfect ? Data collection will be wrong ? Wrong data ?wrong result i.e. remedy ? So we must be well conversant with the different aphorisms of Organon of medicine www.similima.com 2

3. www.similima.com 3

4. www.similima.com 4

5.  www.similima.com 5

6. www.similima.com 6

7. www.similima.com 7

8. www.similima.com 8

9. www.similima.com 9

10. Aphorism 83 Physician�s Special Qualifications Freedom from prejudice Sound senses Attention in observing Fidelity in tracing the picture of the disease What is applicable in each individual case of disease www.similima.com 10

11. Aphorism 84 Expression of patient & its important parts recordings www.similima.com 11

12. Aphorism 85 Fresh line � separately arranged. The process of writing down symptom during case taking The symptoms should be written in 3 steps (84-85) Patient�s reports Attendant�s reports Physician�s observations Very expression of the patient & his friends should be written down accurately www.similima.com 12

13. 3. The physician keeps himself silent and must not interfere during their detailment unless they wander off to other maters. 4. The physician advises them to speak slowly. 5. The physician should take down only the important parts of what the speakers say. 6. The physician should begin a fresh line with every new circumstances mentioned by the patient and his attendants, one below the other and later subsequently when more explicitly explained, be added up. www.similima.com 13

14. Aphorism 86 More precise information For having more precise information in case taking, the physician reads over the symptoms as they were related to him, one by one, and about each of them, he enquires for further particulars as follows 1. Location 5. concomitants 2. Sensation 6. Duration 3. Complaints 7. Causation 4. Modalities 8. Extensions 9. Time of occurrence www.similima.com 14

15. Aphorism 87 No suggestive questions The physician must not frame his questions so as to suggest the answer to the patient If the physician asks suggestive questions, the answer will be in most cases �Yes� or �No�. This will: Mislead to answer in affirmative or negative These will be something untrue These will be half true These may not be strictly correct This sort of answer may take place due to the indolency of the patient. This sort of answer may be made to please the interrogator This sort of answer will produce a false picture of the disease, and an unsuitable mode of treatment then must result. www.similima.com 15

16. Aphorism 88 More special questions Then we will have to collect the symptoms of the parts not detailed before or we will have to enquire into the state of disposition of mind In doing this, the physician only makes use of general expressions, in order that his informants may be obliged to enter into special details concerning them. www.similima.com 16

17. Aphorism 89 More special questions If the physician feels he has not yet gained all the information he needs, he is at liberty and obliged to ask more precise and more special questions. www.similima.com 17

18. Aphorism 90 Observations and Ascertains Hahnemann in his case taking chapters has also advised for any manual or mechanical or laboratory examinations and diagnosis and prognosis by the following sentence. �He then makes a note of what he himself observes in the patient and ascertain how much of that peculiar to the patient in his healthy state. www.similima.com 18

19. This discussion may be made in two steps. Observation of the patient � includes mechanical, manual and laboratory examinations Mechanical examinations include examination by the instruments e.g. stethoscope, hammer, needle, probe, auroscope, ENT set etc. Manual examinations include palpation, percussion and inspection. Laboratory examinations include chemical, microscopical examinations of stool, urine, blood, sputum, X-ray etc. www.similima.com 19

20. 2. Ascertions � may be divided into diagnosis and prognosis The diagnosis may be by the modern conception of the disease- the names of different diseases as per their pathological states etc. or by homoeopathic nosology e.g. acute diseases, chronic diseases and their individual types e.g. Epidemic, Sporadic, Psudochronic, Artificial, True etc. to Intermittent, Mental, Local etc. The prognosis also may be done in both ways By modern way � for the next coming diseases or the effects. By homoeopathic thinking � curable or incurable, the processes of developments to take place after the application of medicine. www.similima.com 20

21. Aphorism 91 If it is a slow case The symptoms and feelings of the patient during previous course of medicine do not furnish the pure picture of the disease. The physician requires Symptoms and ailments which he suffered from before the use of the medicines Symptoms and ailments after they have been discontinued the medicines for several days So when such a slow or chronic case comes from other physician�s hands he must judge the above two points. www.similima.com 21

22. If the patient comes after taking the medicines whose actions are still going on, he will take the following measures The physician leaves him some days quite without medicine. The physician administers something of an unmedicinal nature and defer to a subsequent period. After the subsequent period he takes up the case as per direction set up in the case taking of the chronic cases with the general directions. www.similima.com 22

23. Aphorism 92 If it be of a rapid course The physician must not follow the above advice, because The serious character admit of no delay The physician cannot ascertain what symptoms were present before the employment of medicine The complete picture of the disease will then be the conjoint malady formed by medicinal and original diseases and hence is more serious and dangerous. Here the patient demands prompt and efficient relief. So the physician should Trace out the complete picture of the disease, i.e. conjoint malady formed by medicinal and original disease Amply apply a suitable homoeopathic remedy by the conjoint totality. Thus the patient shall not fall a sacrifice to the injurious drugs he has swallowed. www.similima.com 23

24. Aphorism 93 If it be by some obvious cause � In either acute or chronic cases, the patient or his friends are questioned privately then, Either they will mention it spontaneously. They will tell everything when carefully interrogated www.similima.com 24

25.  www.similima.com 25

26. www.similima.com 26

27. Aphorism 94 The physicians considers and scrutinises the particular circumstances of the patient with regard to His occupation His usual mode of living His diet His domestic situation and so forth � to be the Etiology, maintaining cause or obstacle to recovery. This is known as personal History of the patient. It is so done to ascertain what there is in them that may tend to Produce the disease Maintain the disease In order that by their removal, the recovery may be promoted. www.similima.com 27

28. Aphorism 95 Then he discussed about the importance of minute peculiarities and Lesser Accessory symptoms in taking up a chronic case Minute peculiarities must be attended to because In the disease they are more characteristics They are least resemblances to those of Acute disease, i.e., they are actually the patients� symptoms.� They cannot be too accurately noted The patient becomes so used to their long sufferings that they pay little or not need to the Lesser accessory symptoms. www.similima.com 28

29. The accessory symptoms are Often very pregnant with meaning (characteristics) Often very helpful in determining the choice of remedy and regard them as- A necessary part of their condition, almost as health Forget them sometimes, 15 or 20 years sufferings. Scarcely believes that these Accessory symptoms can have any connection with their principal malady www.similima.com 29

30. Aphorism 96 He also warns about the Hypochondriac patient who detail much. They detail much due to their Great sensitiveness Impatient of sufferings Habit of portraying their symptoms in the vivid colours. Describe their symptoms in exaggerated expressions in order to induce the physician to give them prompt relief www.similima.com 30

31. Aphorism 97 Similarly the indolent patient details less and they detail less due to From indolence From false modestly From a kind of mildness of disposition or weakness of mind and thus Refrain from mentioning a number of their symptoms. Describe them in vague terms Allege some of them to be of no consequence. www.similima.com 31

32. Aphorism 98 We shall attach credence (The mental attitude that something is believable and should be accepted as true) especially to the own expression of the patient, because The patient endeavors to make us understand his ailments In the mouth of the friends and attendants they are usually altered and erroneously stated. The investigation of a true complete picture and its peculiarities demands Special circumspection Tact Knowledge of human nature Caution in conducting the enquiry Patience in an eminent degree www.similima.com 32

33. Special circumspection � The physician should carefully observe and take note of all the thing peculiar to health and disease. He should be cautious, prudent (careful and sensible) and have an examining attitude. Tact � A physician should be skilful and ingenious (showing inventiveness and skill) in managing the feeling of a patient. He should have the right perception in seeing and doing exactly what is best in the circumstance. Knowledge of human nature � The physician should be aware of normal feelings, common reactions in various conditions and needs of the mind at various stages of life. www.similima.com 33

34. Caution in conducting the enquiry � The inquiry should be made with great care and respect to human life. The dignity of the individual should be maintained at any cost. The feelings of the patient should be respected and the physician should try to understand it in each case because the feelings and thoughts make a man, the physician should not scope or confront the past if it is not unavoidable. At any stage he should not enter into unnecessary arguments with the patients. The physician�s attitude and words should not be unpleasing to the patient. www.similima.com 34

35. Patience � the physician should have the quality of being able to listen patiently in order to understand the patient and his sickness. The physician�s patience gives a great relief and satisfaction to the patient and he is encouraged to narrate the story of his sickness by this attitude of the physician. Patience is also necessary to understand a person in totality. This helps the physician to have a controlled reaction while taking a case, www.similima.com 35

36. www.similima.com 36

37. Aphorism 99-102 Hahnemann also has grouped the Acute diseases for proper case taking Hahnemann has grouped the Acute diseases mainly into two. The two main groups are Individual types Sporadic and Epidemic types He has put the sporadic and epidemic types into one group, because The peculiarity or novelty of the diseases of these kinds makes no difference either in their mode of examining or of treating it. Epidemics and sporadics resulting from a contagious principle always remains the same e.g. small pox, Measles, Cholera etc. www.similima.com 37

38. Aphorism 99 Individual acute diseases He also says that the investigation of an acute case is much easy for the Physician. The causes are All the phenomena and deviation from the health of the patient are still fresh in the memory of the patient and his friends These still continue to be novel (unusual) and striking The physician has much less to inquire into. Due to recent origin and nature of disease the symptoms come into notice of the physician without much difficulty. www.similima.com 38

39. www.similima.com 39

40. Aphorism 100 Consideration as an unknown one In case of an acute disease i.e. epidemic and sporadic a physician should study the disease carefully and examine it properly without being biased by earlier experiences. He should treat such disease as a unique and unknown one which might have some similarity in presentation or even in name but there always exists an individual characteristic. Even if the causation is same because of difference in constitution of a person, the effect i.e. the expressions would be always different at some sphere. However, the epidemics caused by the same source are found to be similar in common symptoms. www.similima.com 40

41. Hahnemann has given some special advice in taking up an epidemic or sporadic cases in the following ways: There is no difference either in the mode of examining or treating it, as, the physician must always regard the pure picture of every prevailing disease as it were something new and unknown and investigate thoroughly for itself. He never substitutes conjectures for actual observations He never takes for granted that the case of disease before him is already wholly or partially known He always carefully examines it in all its parts. He knows, �every prevailing disease is in many respects a phenomena of unique character differing vastly from all previous epidemics� He knows,� few exceptions of epidemics resulting from a contagious principle that always remain the same e.g. small pox, measles etc. www.similima.com 41

42. Aphorism 101 Characteristic portrait to be obtained In epidemic cases the totality of disease is only known after the physician makes a study of several cases since the study of one case would only provide a partial picture of the disease. However an experienced physician might get a complete picture by studying a single case of epidemics just as an experiences person can perceive a complete picture by seeing a part alone And thus an experienced physician can prescribe a suitable homoeopathic remedy even after studying a single case or a few cases www.similima.com 42

43. To get the complete picture of an epidemic case It is only possible by a close examination of several cases of every such collective diseases. In that he can become conversant with the totality of its signs and symptoms. The carefully observing physician can, however, from the examination of even the first or second patient often arrive so nearly at a knowledge of the true state as to have in his mind a characteristic portrait of it and even to succeed in finding a suitable, Homoeopathically adapted remedy for it. www.similima.com 43

44. Aphorism 102 Abstracts ascertained from several patients. After a physician has studied several cases, it would be easy for him to get a clearer and more complete picture. He should write them under general symptom and characteristic particulars. These together constitute the totality of epidemics. To know the complete picture of any epidemic, a physician must study its symptoms in several patients of different constitutions. A medicine selected on the basis of this final totality is known as genus epidemicus. It can be used for treating all the persons affected by the epidemic and also as a preventive medicine. www.similima.com 44

45. www.similima.com 45

46. Aphorism 103 Psora must be investigated. Because it is the fundamental cause of all diseases and is the mother of all chronic diseases. From whatever kind of diseases the patient is suffering from, the background is always psoric. It is the soil on which the seeds of the other diseases germinate, grow and develops. Now the question is how? Here Hahnemann advises: www.similima.com 46

47. Just like the processes of finding the specific medicine in epidemic diseases, we shall have to proceed to examine several cases suffering from psoric manifestations. We shall have to note the whole sphere of their symptoms in much more minute manner. In them, one patient only exhibits a portion of their symptoms a second, third and so on, present some other symptoms which are portions of the totality of the symptoms. The whole aray of symptoms of such a miasmatic chronic disease can only be ascertained from observation of very many single patients affected with such a chronic disease www.similima.com 47

48. By the complete survey and collective picture of disease symptoms, the medicine capable of curing whole malady Homoeopathically can thus be discovered. These maladies are at the same time remedies of several patients suffering from such chronic affections. www.similima.com 48

49. Aphorism 104 When the case taking is completed, the most difficult task of the physician is accomplished. The next duty of the physician will be He will consider the CT reports to frame a picture of the disease especially if it be a chronic one He will consider it as a guide in his treatment. He will investigate in all its parts He will pick up the characteristic symptoms He will try to find out a very similar homoeopathic medicine from the list of symptoms of all medicines whose pure effects have been ascertained. www.similima.com 49

50. The duty of a physician when the patient comes to him second time has been discussed in the following manner. After prescribing a medicine, the physician will ask the patient to report him a few hours or days after as per type of disease and medicine with potency. He will then note the effect of medicine and the changes that has taken place in the patient�s state of present health. www.similima.com 50

51. 3. He will have a fresh examination of the patient only on the following points: He will strike out of the list of symptoms noted down at the first visit those that have been abolished (end). He will mark what still remains. He will add any new symptoms that may supervene (developed). He will apply a + sign upon those symptoms which have been aggravated. He will apply a � sign upon those symptoms which have become ameliorated but not completely abolished. www.similima.com 51

52. www.similima.com 52

53. www.similima.com 53

54. Do�s and Don�ts of case taking Do�s of case taking: The symptoms should be written from different sources like patient himself, attendants, physician�s own observations. Data should be collected in patient�s own words. At the beginning the physician should advise the patient to speak slowly. Physician should record important points what patient narrates. www.similima.com 54

55. Physician should begin a fresh line with every new circumstances mentioned one below the other and subsequently when more explicitly (Precisely and clearly communicated) explained, be added up. The physician is to remind the patient in general terms when in his narration he omits to say anything about several parts and functions of his body or about his mental state. www.similima.com 55

56. Special questions are to be asked only when the physician feels that the peculiar, uncommon symptoms of the case has not yet come out in the case taking. Finally the physician has to note down his own observations about the individual peculiarity of the patient in disease and health. www.similima.com 56

57. Dont�s of case taking: Don�t interrupt unless patient or his attendant wanders of to the other matters. Don�t ask any direct question that can be answered by yes or no OR don�t ask any leading question that suggest an answer. If patient coming from other physician In chronic cases the original disease picture is to be obtained by referring to the original symptoms appearing before taking medicine or after discontinuing it for several days when the medicinal effects go away www.similima.com 57

58. In acute diseases that are of rapid course, a complete picture of the conjoint malady is to be taken into consideration and a suitable homoeopathic medicine is to be prescribed An obvious cause may be present in an acute or a chronic disease, which is to be ascertained. www.similima.com 58

59. Concept of Case Taking in Different Types of Diseases www.similima.com 59

60. Case Taking in Individual acute Diseases www.similima.com 60

61. Aphorism 72 Acute diseases are rapid morbid processes of abnormally deranged vital force. In acute diseases symptoms evolve quickly and the patient remembers all of them. Sometimes the disease may be of serious character and demands attention hence the physician must give prompt and efficient aid. www.similima.com 61

62. In acute diseases the chief complaint strike us and become evident to the senses more quickly than in chronic disease and so less time is required for tracing the picture of disease and much few questions have to be asked. Acute diseases are caused by an exciting or acute miasms. www.similima.com 62

63. As a physician you must examine the patient and see what are his symptoms but this is not sufficient. Sometimes there are things that physician cannot know and can�t observe, so here also all sources of getting totality must be examined. www.similima.com 63

64. Dr. Hahnemann said in $99, on the whole investigation of acute disease, or of such as have existed but a short time, is much the easiest for the physician because all phenomena and deviations from the health has been but recently lost are still fresh in memory of patient and his friends still continue to novel and striking. The physician certainly require knowing everything in such cases also, but he was much more to inquire into, they are for the most part spontaneous detailed to him. www.similima.com 64

65. Totality in Acute Diseases In acute disease, the disorder is located in the lower scale of life. The central life force is disturbed somewhat, but the change is more superficial in nature. Hence we should concentrate on the particular symptoms. In acute disease total characteristic symptoms helps in forming totality, one can divide the concept into sector totality and fixed general totality. www.similima.com 65

66. Sector totality contains symptoms with peculiarities in relation to location, sensation, and modalities. Fixed totality covers changes at physical, general and mental level. In all, exciting causes, modalities and other characteristic in relation to physical generals help in forming totality in acute diseases. Also we can consider objective symptoms, pathological type, location etc. as an eliminating symptom. www.similima.com 66

67. Dr. Boericke writes,� often in the course of acute diseases, and in children, where no characteristic symptoms can be obtained, a pathological correspondence may be the only resource, but it is otherwise in the treatment of most chronic diseases. The totality of symptoms changes more rapidly in acute conditions than in chronic. www.similima.com 67

68. Treating Acute Diseases If anybody wants to compare prescribing for acute with prescribing for chronic it will be shown that it is more difficult to select a remedy for acute case than a chronic one. Many seemingly acute conditions are not true diseases but mere indisposition which disappear of themselves under ordinary circumstances when the cause is removed, or yield easily to corrective hygienic, dietic, moral or mechanical measures. www.similima.com 68

69. Homoeopathic remedy in acute disease accelerate the natural process, which is set in motion by the defensive mechanism. Acute disease can be aborted without unfavorable consequences but chronic cases cannot be aborted, e.g. A boil, catarrhal fever etc can be aborted which may not prove harmful in the future. But eczema has to be cured by the proper remedy. www.similima.com 69

70. Prescribing in Acute Diseases Examine the entire complaints and select a drug on the totality of symptoms. If totality indicates drug clearly, give it preferably first in medium potency and watch as far as possible effect of each dose, repeating at first, perhaps every 2/3 hours. If improvement sets in well and good, stop the remedy or at least lengthen the interval between doses while improvement lasts. If improvement ceases, reconsider the case to determine if the indication points to a change of remedy. If they do not, repeat the first chosen drug preferable in a highest potency. www.similima.com 70

71. 3 When a short acting remedy has almost cured the patient, a corresponding deep acting remedy is often required to finish the case but there should be never any haste to give the latter drug so long as the improvement continues and progress is steady. www.similima.com 71

72. Sometimes we meet with �Acute exacerbation of chronic disease.� Dr. Kent says,� Avoid getting confused by two disease, images that may exists in the body at the same time.� A chronic patient, for instance may be suffering from an acute disease and the physician on being called may say that it is necessary to take the totality of symptoms; take only the acute symptoms, which came on since the attack. www.similima.com 72

73. The two things must be separated and acute miasm must be prescribed for. The chronic symptoms will not of course, be present when acute miasm is running because the later suppresses or suspends the chronic symptoms but the intelligent physician not knowing this is so, might wrongly gather together all the symptoms that the patient has, had in a life. The symptoms of the acute attacks are separated by themselves. www.similima.com 73

74. So we should be clear that the case taking in acute disease must confine itself to the acute state only and not to go into the constitutional state of the patient. Sometimes while treating the acute illness the patient may be already taking some medicine, then physician is not having time to wait & watch or to discontinue the medicine for few days in such cases, physician has to form complex picture of present signs and symptoms promptly & then he should select a suitable remedy on present signs symptoms or totality. www.similima.com 74

75. Case taking inepidemic diseases www.similima.com 75

76. In epidemic diseases the disease cause (whether physical or biological) might be identical or of a nature of fixed miasm, giving rise to a general picture of the disease to with all patients conform to but each individual patient adds to this general symptom complex to make each patient unique and different from other patients. www.similima.com 76

77. Ex. In cholera epidemic all cholera patients show common picture as to render the diagnosis of cholera very easy. But if each individual patient is carefully investigated, enough symptoms might be ascertained to individualize one from the other, so that 10 cholera patients might require a different remedy that is most similar in symptoms to each of them, treatment by name of disease is not possible in homoeopathic mode of treatment. www.similima.com 77

78. Individuals vary from each other also generic picture of the epidemic disease may vary from year to year. Hahnemann recommends investigating each sporadic epidemic disease as a new and unknown case and selecting medicine according to its symptoms similarity. www.similima.com 78

79. In epidemic diseases a complete picture of disease becomes familiar and clear by observation of several cases of epidemic. But a carefully observing physician will be able to impress in his mind a characteristic, sketch of it from examining the first few cases and to select the accurate homoeopathic remedy for it. www.similima.com 79

80. Each epidemic possesses a peculiar, uniform character common to all individuals attacked by observing the complex of symptoms peculiar to all the patient this common character will be found to point out the homoeopathic specific remedy for all cases in general and thus we can have a complete picture of the disease by observing the suffering of several patients of different constitutions affected. As they are with disease prevailing at one and the same time with the same disease. www.similima.com 80

81. And this selected remedy will relieve patients who previous to this epidemic had enjoyed good health and who were free from and developed psora. www.similima.com 81

82. Recording of surgical cases www.similima.com 82

83. Importance of Physical Examination and Laboratory Investigations in case taking www.similima.com 83

84. Physical examination and laboratory investigations of the patients has its own scopes in Homoeopathic case taking as evident by the statement �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.� Hence the physician�s observation plays a great role in homoeopathic case taking, such observation includes:- www.similima.com 84

85. Observation about the individual peculiarity regarding the mental condition of the patient in disease and in health. Observation about the individual peculiarity in the physical state of the patient in disease and in health which includes physical examination of the patient in relation to inspection, palpation, percussion and auscultation. www.similima.com 85

86. Laboratory investigations of different pathological types, biochemical, radiological investigations etc., so far available. So after finishing history by the patient and his attendant�s physician duty is to examine patient to find out any systemic abnormality or ask to get pathological investigations in relation to provisional diagnosis, to rule out different possibilities which helps to diagnose the case nosologically. www.similima.com 86

87. Now nosological diagnosis plays important role in relation to analysis and evaluation of symptoms and also in prescribing the proper similimum. These nosological rubrics are one of the components of totality in many cases to get group of remedies. www.similima.com 87

88. Importance of Diagnosis in Case Taking www.similima.com 88

89. Diagnosis: Gives importance to the common features of the disease. Diagnosis ascertains the management, prognosis, course and complications and necessity of surgical interference etc. Thus diagnosis of disease gives idea of pathogenesis, functional disturbances and surgical changes, which is very much useful in analysis and evaluation of symptoms. www.similima.com 89

90. Diagnosis oriented treatment is necessary where the patient is either unconscious or dumb or has very few indistinct unqualified symptoms or there is serious danger to the patient�s life as in drowning, lightening, shocks etc. Diagnosis helps for the selection of potency and repetition of dose. Diagnosis of the case is important for repertorization because in many repertories there are pathological rubrics that can be considered while prescribing. www.similima.com 90

91. 6. Diagnosis gives the idea of patient�s personality and mechanism of production of symptom, location, the pathological changes, Pathogenetic agent�s etc. so by knowing this, it is easy to select proper symptoms for repertorization. 7. To get totality of symptoms, knowledge of diagnosis is important because it helps to determine the individual characteristic symptoms. 8. After repertorization, selection of remedy and its potency has important value and by diagnosis of the case we are able to decide whether pathological changes are far advanced and have affected any of vital organs and it conditions are serious following measures are contraindicated Use of deep acting constitutional remedies like Silicea, Lycopodium, Sulphur. Use of high potency. Frequent repetition of deep acting remedy. www.similima.com 91

92. 9. It helps to make comparative assessment of the therapeutic results 10. Diagnosis is useful to differentiate between common and uncommon symptoms. Examples: Excess thirst and craving for sugar is common in diabetes. Vomiting without nausea becomes common in intracranial tumors. Occipital headache on walking in morning becomes common in hypertensive patients. www.similima.com 92

93. Case Recording www.similima.com 93

94. Case recording is the practical and systematic recording of the information gathered during the case taking session. Here the patient�s story i.e. symptoms and complaints are converted in standard case recording format, which vary according to individual physician�s concept. www.similima.com 94

95. Case recording has to be done as the case is taken according to the general directions (i.e. Do�s and Don�ts of case taking) explained by Dr. Hahnemann in the practical part of Organon of Medicine. Recording of the case is the foremost and most essential step, which gives further planning to the procedure. After converting data in format one can understand whether the collected data is complete or incomplete and helps in asking more details. www.similima.com 95

96. There are certain precautions while recording the case: All the symptoms and complaints should be recorded in narrator�s own language without any mutilation Symptoms and complaints should be recorded in proper intensity, felt and observed in the patient. www.similima.com 96

97. Case recording is important for: The proper assessments of the case for the first prescription. Knowing the behaviour of the remedy prescribed. For second prescription. Follow up purpose. www.similima.com 97

98. Recording and Interpretation Need of a case record has been emphasized by all the stalwarts for various essential purposes. Every case can be a piece of learning. Therefore, it is imperative to have it recorded properly. Since it is almost impossible to keep all the data intact without any distortion, the necessity of a proper recording has been felt acutely. www.similima.com 98

99. The purpose of a case record is to keep all the information adequately and accurately recorded for future references. Case record should communicate the exact picture of the patient that has been obtained by the physician. This is possible only when recording is done properly without being hindered by any subjectivity of the physician. www.similima.com 99

100. Very often it is noticed that all the information of the sick person do not find a place in case record. While the physician might fail to record some information, he might unduly focus on some other aspect. All the events and effects should be recorded without any interpolation or deletions. While recording, beginners are cautioned not to get influenced by the symptoms of drugs as recorded in the HMM. www.similima.com 100

101. Very often the use of technical terms can create confusion, so it should be avoided, but at the same time, physician should apply common sense while noting down the picture in patient�s own language. The physician should be careful while interpreting the words of the patient as the prejudices of the physician might crawl in here without his awareness. www.similima.com 101

102. Intensity of symptom should also be given due consideration while recording. Each ad every symptoms should be recorded by putting marks above it For example: Pungent � Craving 3 (More intense) Pungent � Craving 2 (Intense) Pungent � Craving (Moderate) For effective repertorization, precise recording is very crucial for proceeding further with the subsequent steps. www.similima.com 102

103. Record Keeping www.similima.com 103

104. Definition: Record keeping is a process of keeping the record of the complaints of the patient and the treatment given to the patient. But most of the doctor do not realize its importance and do not feel the necessary of keeping a record while others feel that record keeping is the laborious work or task. www.similima.com 104

105. Different Methods of Recording the Case Card System: Specimen of indexing the cards employed for recording is as follows www.similima.com 105

106. Bound register System/Closed Method: Recording the complaints and treatment given in a big notebook also called as closed method Case is arranged data-wise with folio number in the register. Record of a chr case is transferred from one folio to another and subsequently to another register. This type of recording the case is more suited in private medical practice. www.similima.com 106

107. 3. Loose Leaf folder: Advantages: This method we can keep the record on large scale. Cases are arranged serially or alphabetically Record of a chr case is available at one place. Records of the members of one family can be located in a single folder. It is a flexible system With therefore useful in big Institutions. Disadvantages: Initial cost is more. It essentially requires clerical assistance. www.similima.com 107

108. File system: Book form: Many physicians they use to give booklet of questionnaires to their patients in which record is printed with question. So after writing answers to the asked questions by the patients book is used as a record of that patient. 6. Another new method of recording the symptoms of the patient and the treatment given to the case is by using computer with different homoeopathic software. www.similima.com 108

109. Evolution of concept of Record Keeping Dr. Constantine Hering: A homoeopathic doctor as a faithful bookkeeper. Hering begins his article on Hahnemann�s idea of the Homoeopaths duty of making a written scheme of the image of the disease. Hering summaries the principles contained in the Organon in the following manner, to listen, to write down, to ask questions, and to arranged, then described his own system of record keeping. www.similima.com 109

110. First her refers to the writing material and recommends the use of pencil and of smooth, unruffled paper to ensure flowing handwriting, which enhances legibility. He further recomemnds loose sheets, instead fo bound journal. Each case history should start with the name of patient the day on which visit took place. At the bottom of each entry Hering always notes the weather condition and position of the moon. The rest of the page is reserved for patient�s symptoms, starting a fresh line with every new circumstance or sign. www.similima.com 110

111. Dr. Boenninghausen was the first to publish case histories recorded by Hahnemann himself during the last month of his medical practice in Paris. Dr. Boenninghausen recommends the elaborate , convenient and practical scheme for recording the case histories. Every page is divided into three columns, containing, as much as possible in alphabetical order First the house or family name, then the Christian name, the dwelling place and age, lastly the volume and page in number. www.similima.com 111

112. The first column contains the name of the patient who was on the list when the book was started. The second is for new patients, bearing the same family name. Third is for those whose family name is not found. Among that entered with such an arrangement the register will last a long time and will not need to be copied off so frequently. www.similima.com 112

113. Dr. J. T. Kent: Dr. Kent wrote,� it should be known first of all, that the true homoeopathician write out the symptoms or each and every patients and preserve record for the benefit of such patient and the art of healing.� Lutzes: Scheme of record keeping � due to the enormous expansion of his medical practice he suggested an ingenious (Showing inventiveness and skill) filing slip system (file management) that was revolutionary. www.similima.com 113

114. Importance of Record Keeping For proper assessment of the case or for forming the conceptual image of the patient � Without noting down all the complaints of the patient one cannot assess the image of the disease. To find the chronic miasm behind the whole case; by keeping the record of the symptoms Homoeopath can assess the miasm responsible for the given chronic disease and thus he is directed to select the medicine according to the miasm. www.similima.com 114

115. In an acute case from the records we can analyse the case that whether the case is common or uncommon. For follow up of the case � when the record of the medicine is maintained it helps to follow the case judiciously and scientifically. Curability and incurability of the case � by proper case record the curability and incurability of the case can be judged and thus we can assure the patient about his treatment. www.similima.com 115

116. Record keeping reflects the skill of the physician � records speak of the failure and success of past and present and serve as a guide for future. For clinical teaching and for proving the superiority of Homoeopathy. If the other discards the case as an incurable or the physician of other system label certain cases s hopeless but there are excellent homoeopathic prescribers who successfully treat such patient and bring them back to the healthy state. www.similima.com 116

117. If such records are kept, they can guide the younger homoeopathic generation to cure so called hopeless or incurable cases and thus this recorded document can prove the superiority of the system and for clinical teaching for future Homoeopaths. Thus it can help for publishing the observations and results that we get from our clinical experience. 6. Helps to observe the remedy reactions and progress of the case so that we can know the judgement of the action of the remedy. www.similima.com 117

118. Miasmatic cleavage: can be judged from the symptoms with proper case record and without knowing the miasm application we cannot prescribe miasmatic medicine or intercurrent remedy. For research purpose � Record keeping helps for publishing the observations and results of the homoeopathic case For legal procedures � record keeping helps for reference in legal procedures. www.similima.com 118

119. Selection of second prescription and for finding out related medicines till the case is completely cured When the record of medicine given to the patient is maintained, it helps us to follow the case judiciously and scientifically i.e. record keeping helps use for second prescription to scrutinize the action of medicine after its application. Thus we can apply the antidotal medicine, complementary medicine, palliatives, new medicine or simply sac lac as the case progresses. New symptoms - record keeping helps to inform about the new symptoms thus it guides the physician to proceed in right path. Helps to know the change and for obervation of hering�s law of cure www.similima.com 119

120. Ability and disability � restudy of records will confirm the physician himself as regards to his ability and disability of different cases. The physician in the cases can make corrections where he has failed for the first time Record keeping helps for repertorial analysis. It helps for proper Repertorization that leads to the selection of proper similimum. www.similima.com 120

121. Case Processing i) Pre-requisites of Repertorization Symptomatology Analysis of the case Construction of totality of symptoms of the case 1. Acute totality 2. Chronic totality Dominant miasm of the case Evaluation of symptoms Synthesis of case of portrait building (conceptual image) (according to Hahnemann, Boenninghausen, Kent, Boger) www.similima.com 121

122. Case Processing i) Pre-requisites of Repertorization Symptomatology Analysis of the case Construction of totality of symptoms of the case 1. Acute totality 2. Chronic totality Dominant miasm of the case Evaluation of symptoms Synthesis of case of portrait building (conceptual image) (according to Hahnemann, Boenninghausen, Kent, Boger) www.similima.com 122

123. Case Processing i) Requisites of Repertorization Selection of Repertory (As per case) Repertorial totality (Repertorial syndrome) Conversion of symptoms into rubrics (Knowing the language of repertory) Permutation and combination of rubrics so as to truly represent symptoms of the case Formal Repertorization with the help of appropriate repertory for the case www.similima.com 123

124. Case Processing i) Analysis of Repertorial Result: Comprising of i) Comparing the competing remedies ii) Reference of MM for those symptoms of totality which are not taken for Repertorial totality Selection of remedy with justification i) Acute prescribing ii) Chronic prescribing www.similima.com 124

125. Case Processing i) Requisites of Post Repertorization Administration of remedy Selection of potency and repetition of dose Remedy response � its interpretation and follow-up action. Second prescription Follow up of the case Use of intercurrent � and antimiasmatic remedy if required General Management Auxiliary measures as per the case www.similima.com 125

126. Symptomatology Subjective and objective symptoms Common and uncommon symptoms General and particular symptoms Complete and incomplete symptoms Chief and concomitant symptoms Recent and old symptoms Pathognomic symptoms Keynote symptoms Eliminative symptoms Determinative symptoms Basic symptoms www.similima.com 126

127. Diagnostic symptoms Negatives symptoms Accessory symptoms Alternating symptoms Clinical symptoms Recurrent symptoms Periodical symptoms Paradoxical symptoms Accidental symptoms Pathological generals Queer, rare and strange symptoms www.similima.com 127

128. Analysis of the case After interviewing the patient and completing the physical examination, a homoeopathic physician is in possession of a large no. of symptoms. The deviations at an organic and systemic level and the changes in the whole person construct a case. The case, no doubt consists of a variety of expressions, it has to be analyzed and synthesized to understand the whole phenomena. www.similima.com 128

129. The depth of the case and extent of each expression is not fully available to the physician unless he tries to analyze each symptom and makes an effort to understand it in respect of the entire presentation. One must not forget that each symptom contributes to the whole picture. www.similima.com 129

130. Case analysis is a logical resolving or separating of the whole Symptomatology into different components and further splitting them into viable units as per their hierarchy. The process is not a mechanical division or merely a classification of facts, but includes the necessary tracing of the source and so discovering the interaction of the patient and the environment underlying the individual phenomenon of disease. www.similima.com 130

131. Generally analysis of a case begins with classification of all the data collected from the patient into common and uncommon symptoms. It is imperative that the physician glance through the whole data gathered after case taking without being prejudiced about any symptom. In the process he should be able to grasp the whole picture in relation to the patient and his parts. www.similima.com 131

132. The symptoms in relation to the chief complaint(s) are put together and should be divided into their components, i.e., location, sensation, modalities and concomitants. Each component of a symptom has its own importance in relation to the construction of a totality and selection of a remedy. Therefore, due care is to be exercised while splitting each symptom into its components. The physician should be able to spot rare, peculiar and striking symptoms in the whole case. www.similima.com 132

133. The analysis of a case is governed by various principles of practice, hence, sometimes a little variation in the method of analysis can not be denied. But one should not forget that different stalwarts, though they have differences in philosophy, have a great deal in common too. All great practitioners like Boenninghausen, Kent and Boger have given importance to the CAUSE and EFFECT in disease. www.similima.com 133

134. Therefore analysis of a case must be able to provide these elements of the case. The characteristic expressions, which individualize the process of a disease, should also be evident to the physician after analysis. Thus, analysis helps a physician to get the following information: www.similima.com 134

135. Causation � Ailments from, physical and emotional causative modalities General modalities � Aggravations and ameliorations, relation to heat and cold. Characteristic particulars (modalities, etc.) Rare, peculiar and striking symptoms. Concomitants Common symptoms with L, S, and M. www.similima.com 135

136. This product of analysis can be used for the synthesis of a case or it can be used for systematic repertorization. For the purpose of repertorization it needs to be rearranged as per the philosophy of the repertory used. Proper analysis needs a keen and analytical mind. The physician should be able to analyze every symptom in depth and to arrange it logically. It is very important to have a clear cut and well laid out case record. All these things require great patience and time. www.similima.com 136

137. Totality of Symptoms �Totality of symptoms is the outward reflected picture of the internal essence of the disease, that is, of the affection of the vital force.� Totality is simply the complete picture of the disease. The totality is to the disease what the man, the ego, is to his organism. It is that which gives individuality and personality. Totality is an abstract form or image, comprising all that can be known of the artificial disease, so arranged as to have an individuality of its own www.similima.com 137

138. Hahnemannian Totality Hahnemann in his initial practice has taken the entire expression of the patient for the totality and this whole picture should match with that of the similar expression in the MM. This procedure is too tedious to find out the exact remedy and the result is not so satisfactory and later in the Aphorism 153 states that � �In this search for a homoeopathic specific remedy, that is to say, in this comparison of the collective symptoms of the natural disease with the list of symptoms of known medicines, in order to find among these an artificial morbific agent corresponding by similarity to the disease to be cured, the more striking, singular, uncommon and peculiar (characteristic) signs and symptoms of the case of disease are chiefly and most solely to be kept in view; for it is more particularly these that very similar ones in the list of symptoms of the selected medicine must correspond to, in order to constitute it most suitable for effecting the cure.� www.similima.com 138

139. Hahnemann is praising Boenninghausen for publishing the characteristic symptoms of the Homoeopathic medicines and his Repertory (Repertory of Antipsoric) in the foot note of 153 Aphorism. Here the construction of his book is in the complete symptom pattern in each chapter that is, L, S, M, and C. So if we go through the Aph 86 Hahnemann asks to interrogate further upon: www.similima.com 139

140. Location Sensation Character Onset Duration Frequency Intermittent Time Modality So if we combine the Aph 86 and 153 the acute totality of Hahnemann is complete. That is, the striking, singular, uncommon and peculiar (characteristic) signs and symptoms is nothing but the concomitants. www.similima.com 140

141. So the ACUTE TOTALITY consists of: Concomitants Modalities with time Sensation and character with onset, duration, frequency. Location This concept was followed in the construction of Repertories like repertory of antipsorics, Lippe�s Repertory and Boger Boenninghausen Characteristic and Repertory. Hahnemann has given individual totality for each class of disease that is according to Hahnemann Classification of Disease in the Organon of Medicine. www.similima.com 141

142. In case of epidemic diseases (Aph 100, 101, 102 and 103); severe; cases different stages of disease have to be considered before reaching a genus totality. As each case add a new symptom to the totality. Never see the past experience to find out the present genus epidemicus. GENUS EPIDEMICUS TOTALITY (� 102) Peculiarities of the collective disease. Peculiar generals www.similima.com 142

143. Chronic Totality In case of chronic disease, � 210 says � ��.. so called corporeal diseases the condition of the disposition and mind is always altered; and in all cases of disease we are called on to cure the state of the patient�s disposition is to be particularly noted, along with the totality of the symptoms, if we would trace an accurate picture of the disease, in order to be able there-from to treat it homoeopathically with success.� www.similima.com 143

144. In addition to this � 94 � �In these investigations, the ascertainable Physical constitution of the patient (especially when the disease is chronic), his moral and intellectual character, his occupation, mode of living and habits, his social and domestic relations, his age, sexual function, etc., are to be taken into consideration.� www.similima.com 144

145. � 88 quotes: � If in these voluntary details nothing has been mentioned respecting several parts of functions of the body or his mental state, the physician asks what more can be told 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 expressions, in order that his informants may be obliged to enter into special details concerning them.� www.similima.com 145

146. Foot note of � 88: For example: What is the character of his stools? How does he pass his water? How is it with his day and night sleep? What is the state of his disposition, his humor, his memory? How about the thirst? What sort of taste has he in his mouth? What kinds of food and drinks are most relished? What are most repugnant to him? Has each its full natural taste, or some other unusual taste? How does he feel after eating or drinking? Has he anything to tell about the head, the limbs, or the abdomen? www.similima.com 146

147. So after clubbing all these above aphorisms i.e. 88, 94 and 210, the CHRONIC TOTALITY of a true chronic disease becomes clear. That is: Change in Disposition Mind Physical Constitution Totality of Symptoms This is nothing but what Kent has narrated his totality. www.similima.com 147

148. INTERMITTENT DISEASE: (� 231-244) In intermittent disease the totality is same as that of chronic diseases, but an additional symptom that is, symptoms in between the attack should be the chief guide to the final selection of the drug. ONE SIDED DISEASE: The presenting Symptomatology is the guide for prescription due to lack of characteristic Symptomatology. Here if the Symptomatology is changing with each prescription then depending upon the totality the drug also varies. www.similima.com 148

149. Boenninghausen�s Totality Boenninghausen has narrated seven verse or rubrics required to get the complete image of the disease. They are in hierarchy given below: QUIS (Change in disposition of personality or individuality) QUIBUS AUXILIS (Accompanying symptoms) CUR (Cause) QUAMODO (Modalities) QUANDO (Time) QUID (Nature of the disease) UBI (Seat of the disease) Boger recommends this totality in BBCR. www.similima.com 149

150. Kent�s Totality MENTAL GENERALS: Symptoms concern with WILL: (Love and hates, Desires and aversions, Fears, Anger, irritability, Grief, cheerful, sadness, happy, Loquacity). A strongly marked mental symptom will always rule out any number of poorly marked symptoms of lesser grade. Those belonging to the rational mind, so called INTELLECTUAL MIND (UNDERSTANDING): (Delusions, Delirium, Dullness, Imbecility, Confusion, clairvoyance) Those belonging to the MEMORY: Absentminded, Forgetful, Mistakes, etc. www.similima.com 150

151. PHYSICAL GENERALS: Symptoms related to the entire man and his entire body or his blood and fluids Relation to heat and cold, to storm, to motion, to rest, to night, to day and to time. Menstrual History � complaints before, during and after. Sexual symptoms Relation to eating Bowel Habits before or after stool � inclusive of both symptoms and modalities Character of discharge from ulcer, uterus during menstruation, ears and from other parts. PARTICULAR SYMPTOMS Modalities of the parts affected. www.similima.com 151

152. Boger�s Totality Modalities Causation, time, temperature, open air, posture, being alone, motion, sleep, eating and drinking, touch, pressure, discharges etc. Mind: Irritability, sadness, fear, placidity (A feeling of calmness) Sensations: Subjective symptoms: Burning, cramping, cutting, bursting, soreness, throbbing, thirst Objective symptoms: Demeanor, restlessness, nervous excitability, facial expression, torpor, state of secretions, color abnormality, odor. Parts affected: Organs, right, left www.similima.com 152

153. Miasmatic Assessment After forming the totality of the case, physician should assess miasmatic background that helps in deciding the plan of treatment. Knowledge of miasm is the bse of Homoeopathic learning and practice. In real sense, without the knowledge of miasm, there is no Homoeopathy. Theoretical aspect of miasm is already explained in may books of philosophy and also in other books. www.similima.com 153

154. Dr. Hahnemann introduced concept of miasms in the treatment of chronic conditions. Understanding of miasm totally depends on present characteristics of the patient. Miasm behaves as an obstacle if not removed before any cure is desired. There are two types of miasm: Acute Chronic www.similima.com 154

155. Acute miasm is characterized by suddenness, violence and stormy nature. If is of two types � recurring and non recurring The chronic miasm is the real fundamental cause of all kinds of chronic disease these are Psora Syphilis Sycosis The Psoric miasm is expressed through weakness, skin complaints, allergies and many other characteristics www.similima.com 155

156. The Syphilitic miasm is characterized by destructiveness. There is introversion destructive, ulceration and destructive temperaments. The Sycotic miasm is eliminates energy outward in the form of warts, tumours, overgrowths and many pathological discharges Final aim of miasmatic assessment is to classify different group of symptoms as per the miasmatic placement and to determine the most dominant miasm and other miasm in the case. www.similima.com 156

157. About miasms, Dr. Kent wrote that, these chronic disease may exist either in an active or a latent condition and may present themselves in three ways. Viz. 1. As a single miasm 2. Two or three miasms co-existing or separate but only one is active at a time. 3. Two or three miasms forming a complex. But to come to the point, we must attack the one that is uppermost at the time and ignore the symptoms of those that are latent. Except in the last monstrous phase where two or three form a complex, which is a rare thing and seldom brought about except by the prolonged abuse of unsuitable remedy. www.similima.com 157

158. Evaluation of Symptoms Evaluation of symptoms implies the principle of grading or ranking of different kinds of symptoms in order of priority that are to be matched with the drug symptoms. The key for similimum is the grading of symptoms. After analysis of symptoms physician has to determine quality and value of each symptoms. www.similima.com 158

159. Homoeopathy is based on individualization of patient as well as drug. Every individual is characterized by some unique features, which serve to denote that particular individual belong to some class or group and drug are to be matched first and given in the highest order of priority in selecting the similimum. Actually evaluation is necessary for qualitative matching of remedy. www.similima.com 159

160. It is a well known fact that all the symptoms in a case are not equally important. After taking the case, a physician comes across quite a large no. of symptoms which have to be evaluated in order to arrange them hierarchically. Symptoms expressed at various planes need strict interpretation in order to understand their importance. www.similima.com 160

161. Due to the terminology of modern medicine and the treatment that patients have received from non-homoeopathic physicians, the emphasis, which the patient himself places upon symptoms, is often misleading. Therefore a homoeopathic physician has to differentiate between important and unimportant symptoms from his angle. This is not a very easy task. www.similima.com 161

162. Dr. Elizabeth Wright writes that, evaluation of symptoms is, perhaps the most important part of the Homoeopathic technique and for a beginner, one of the most difficult. But in fact it becomes easy and automatic tasks if one adhere strictly to the principle and philosophy of Homoeopathic practice. www.similima.com 162

163. Evaluation of symptoms is a process that determines the significance and importance of expressed symptoms �an external manifestation of the internal essence of the disease. The phenomenon of a disease i.e. internal turmoil produces change, which is expressed in the form of various functional deviations and limitations. All these deviations are noted and noticed while taking a case. The physician will be at a loss if he does not know how to receive this vast information and put them into a correct order. www.similima.com 163

164. The purpose of evaluation of symptoms is to form a comprehensive portrait of the disease so that a similar portrait can be found out in the HMM. It is needless to say that any error in forming the portrait will lead to an incorrect similimum. In the whole case the �generals� are to be looked for. Among the generals the most imp. Symptoms are those, which relate to the basic love of life and various emotions. www.similima.com 164

165. The next in importance could be changes in his ability to comprehend and dreams, which are closely allied to the mental state. The general expressions on a physical plane are next important symptoms in hierarchy. Another category of the imp. Symptoms is unexpected deviations, rare and peculiar symptoms, individualizing characteristics which enable the physician to settle down to a few medicines and to ascertain which of these is more imp than others or in other words the similimum. www.similima.com 165

166. Symptoms pertaining to the region represent the part and therefore they are comparatively less important. In fact, one important general can over rule several particular. Particular symptoms become important when they are qualified by modalities. There is divergence of opinion as to the proper place and importance of pathology and objective symptoms (such as redness of the orifice). In the Kentian method, these are placed relatively low, whereas in Boger�s method, as given in general analysis, stresses the importance of pathological generals. Objective symptoms are given more importance because they can be clearly assessed. www.similima.com 166

167. Dr. Elizabeth Wright has given very practical suggestions for evaluation of symptoms. She suggests, �As soon as the case is taken and the physician sits down to study it, he will find it useful to run down the list of symptoms and mark with �M� opposite pathology, �P� opposite the particular and �O� for objectives. For further classification, he may underline any peculiar symptom in red�. This exercise undoubtedly is very useful for beginners, but it can prove equally beneficial to all practitioners www.similima.com 167

168. Evaluation of Symptoms www.similima.com 168

169. Synthesis of a Case The word �synthesis� means making a whole out of parts; the process of combination of separate elements of thought into a whole. The most important elements of a case are �generals� which form the outline of the image or portrait. Important particulars doe the work of filling up the details of the image. Thus the image of a case is formed by syntesis. www.similima.com 169

170. Case synthesis can also be defined as the process of rearranging the information obtained from case taking to form a comprehensive and conceptual image. Rearranging of the information must be done according to the strict principles of evaluation of symptoms. Therefore, case analysis precedes case synthesis. It has been observed that a beginner obtains more particulars and common symptoms during case taking, whereas seasoned practitioners get more generals. www.similima.com 170

171. The presence of common symptoms and excess of particulars do not help to make a distinctive image. On the other hand generals give a strong individuality to the image. The outline of the image formed by generals indicates a small group of remedies. These remedies can be differentiated further with the help of particulars, which ultimately leads to the similimum. www.similima.com 171

172. www.similima.com 172

173. Requisites of Repertorization 1. Selection of repertory www.similima.com 173

174. www.similima.com 174