Case Taking – Study of Patient

Data Collection –

This is the first step in Homoeopathic practice. A patient approaches us with certain complaints or symptoms. Study of symptoms forms the most important aspect of Homoeopathic practice.

Symptomatology

Any symptom is to be completed, as far as possible, as to its location, sensation, modalities and concomitant.

Location –

Location is the part of the body where the symptom is felt. For example, a patient has headache, we have to inquire further. It may be in the frontal region, occipital region and so on. The pain may radiate. For example, the headache may start in frontal region and radiate to occiput or vice versa. Sometimes it is difficult for a patient to point out location. Take the example of nausea. As nausea is related to gastric function, stomach is taken as location. Another patient may point out at right hypochondriac as the location of pain. It may be due to liver involvement. Here a physician is free to put liver or right hypochondriac as the location depending on his perception of the cause of pain. In symptom like fever the location can be put as general.

Sensation –

Sensation is what exactly a patient feels. For example, the burning pain, stitching pain, pulsating pain etc. Temporal dimensions are considered. For example, the pain may appear suddenly and disappear suddenly. It may be intermittent or continuous.

Sometimes a patient describes the sensation in a peculiar way. For example, he feels as if floating in the air or sensation on the skin as if ants are crawling. One has to note it down in the same words. Whether it is hysterical or otherwise is to be decided later. Here comes the question of language. If a patient tells us in different language, one has to be careful in translation.

Modality –

Modality means modifying factors for the symptom. It may be aggravation or amelioration. Imagine a chemist applying a series of tests to identify a specific chemical. In similar way here, a physician considers various factors either aggravating or ameliorating the symptom. The purpose is to identify a specific reactive pattern of a patient.

There are number of factors to be considered under modality either as aggravation from (denoted as <) or amelioration from (denoted as >). For example, the condition may get worse at particular time, the pain may be ameliorated by lying down on abdomen, vertigo may be ameliorated by vomiting etc. Boger-Boennighausen’s characteristics and repertory has a separate chapter on modalities.

Concomitant –

Concomitant means an accompanying complaint or the symptom. For example, a patient with fever may feel weak on the first or second day. Here weakness is a concomitant. Another patient may be thirstless during fever even in summer days. In this patient thirstlessness is a concomitant.

Now take a case of ulcerative colitis. It is a chronic disease. This patient also suffers from intermittent headache which is aggravated between 4 to 8 pm. In this case headache as well as modality associated with it is to be taken as concomitant. The lesson is, in chronic cases, where the phenomenon is studied over a period of time, the symptoms occurring during that time period are all concomitant symptoms.

Quite often, a symptom may be incomplete in the sense that it lacks a definitive sensation, modality or concomitant. Even then it is noted down.

Symptoms related to physiological status –

Physical appearance might be peculiar. For example, tall, obese, fair complexion etc. facial expression may be anxious, worried and so on.

Eating, drinking, defecation, urination, perspiration, menstruation in females are all normal physiological actions. There may be some peculiarities attached to it. A patient may perspire excessively, he might be sleeping in particular position, similarly tendency to easy suppuration etc. are to be noted down. These are not the symptoms as per the conventional meaning of the term.

In homoeopathy these are regarded as symptoms as they denote constitutional peculiarities.

Psychological state –

This is an important aspect in the study of patient in Homoeopathy, although the most difficult one. Psychology denotes study of mind. Mind is an abstract concept. What is the physiological basis of psyche or mind? We know from physiology that certain areas in the brain are associated with thought process. For example, limbic system is associated with emotional thought, memory centre is in hippocampus. The mechanism underlying the thinking process is not known. What we know is that the process which result into production of thoughts at every moment.

What are the different varieties of thought? How to know the thought of our patient so that we can recognize his mental state. Let us take one example.

There is a ceremonial event in a hall which is decorated for the function. At one place lots of laddoos are arranged in attractive manner. One gentleman enters and says, “ohh good, I love laddoos”. (emotional thought of love/ attachment). Another lady enters and says, “How these laddos are arranged!

Shabby!” (anger/irritability). One obese person enters and says, “I love laddoos but I have to control. I have diabetes (reasoning – intellectual thought). Mr. X enters and says, “I know some people will take the laddoos and left it in a dish. What a waste of money ! it would have been better, if they distribute these laddoos to the beggars outside the hall (humanitarian thought).

The lesson is in the same environment thinking is different that is why it is difficult to read anybody’s mind.

How to recognize in a patient his thinking pattern?

One way of knowing is to ask him directly. That is a very crude way. No one will tell us about his jealousy, hatred feeling or fear because everyone wants to portray oneself as reasonable and good individual.

A gateway to know patients mind is to hear his life story. The circumstances in which he was brought up, his feelings/opinion about his home people, friends, his activities, social interactions and so on. To inquire and discuss it and derive from it the mental state is an art which very few of us can master. In brief there is no standard way to gather data to assess his mind.

General symptoms –

As per the standard teaching general symptoms represent what troubles patient as a whole. For example, I feel giddy, uneasy etc. As against it, if a patient says that ‘I have pain in the throat’ it is a particular symptom. However, if it occurs at 3 or more locations it is categorized as general. For example, if patient has burning in abdomen, throat and feet then burning becomes a general symptom. Many times, with this yardstick it becomes difficult to find out general symptoms in the case. Instead, if we take a broader view

following symptoms can be put as general.

1. Time – if the trouble is aggravated or ameliorated at particular time.
2. Temperature, weather, air, season – These are to be studied separately. A patient may say he is worse in sun which is different than someone telling us that he is aggravated in summer. However, both indicate that patient can not tolerate heat therefore heat < can become general.
3. Physiological process – urination, menstruation, breathing etc. are normal physiological actions. Any complaint occurring before, during and after that can be put under general.
4. Position of the body, movements and other actions – it can be general or particular. For example, if a patient says his headache is < by lying down on abdomen, it is a particular symptom. Another patient may say he prefers lying down on abdomen, then it is a general.
5. Pathological condition – there may be aggravation or amelioration for example, after hemorrhage, injury etc.
6. Physical factors – covering pressure, rubbing, light etc. are physical factors. It can be general provided it indicates a general reactivity. For example, redness of eye < by light is particular, if patient says he does not like too much of light, it is general.
7. Discharges – character and peculiarities of the discharges can be general. For example, expectoration may be thick, offensive, yellow colour and so on.
8. Sides of the body and radiation – symptom may be on the right side, left side, radiate diagonally, inward direction etc.
9. Alterations – the symptoms may alternate. For example, piles alternating with rheumatism, skin symptoms alternating with respiratory symptoms.
10. Craving and aversion for a particular food or aggravation or amelioration therefrom will be general but low grade general.

One can refer to sensation in general in Boger-Boennighausen’s characteristics and repertory.  

Characteristic particular:

Generally, a case is full of particulars. For example, headache, nausea, itching and several others. It is important to find out peculiarities in the symptom and such symptoms become characteristic particular. These are indicative of individuality. When does a symptom become characteristic?

1.  Unexpected occurrence of symptoms  For eg. – Dryness of mouth but no thirst. > by cold damp weather in Rheumatic complaints.

2. Intensity of the symptoms – Intensity of symptoms is given in the repertory by marks 3,2 and 1. Therefore, burning³ pain, stitching³ pain become characteristics by their intensity itself.

3. A particular symptom which is opposite to the general can be regarded as characteristic. For eg. Lycopodium in general < heat except stomach and Rheumatic complaints.

4. Negative symptoms – A drug may have a few symptoms so predominant in their pathogenesis that their absence indicates peculiarity. For eg. In case of Phosphorus one expects < change of weather.

5. Locations – Certain drugs have predilection for specific locations. For eg. Hekla lava for gums, Nitric acid for axillary lymph node etc.

Recording the data –

The reader may wonder how to inquire and note down all these different categories of symptoms.

Although there is no standard way following guidelines will be useful.

Chief complaint (s) –

Try to complete each symptom as to its location, sensation, modality and concomitant. Patients are not accustomed to such detailed interrogation. Therefore, after asking question he has to be given little time to think. On the other hand, the novice in the field may be unaware of the type of information to be gathered. The study of Kent’s repertory and Boger-Boennighausen’s characteristics and repertory (the section on general symptoms and concomitants) will be useful in knowing the details of such inquiry.

Associated complaint(s) –

This applies to chronic cases, as the phenomenon is to be studied over a period of time. Here also L/S/M/C are to be noted down.

Physiological status –

Physical appearance, skin and appendages (hair, nails) along with perspiration, digestion and related functions like aversion, craving, stool etc. urination, menstruation, sexual function are to be noted down with peculiarities if any. Here one has to pay attention to concomitants associated with physiological acts for example, any trouble either aggravation or amelioration for example- stool before, during, after and coition – before, during, after etc.

Family history and developmental landmarks –

Family history of major illnesses especially to parents and siblings needs to be noted down. By now, a patient is relaxed, and one can inquire about his life from childhood till date. Both physical illness with its details and also psychological make up can be assessed.

General symptoms and characteristic particulars –

At this stage read the data quickly and note down generals and characteristic particulars. Try to complete the missing links by asking relevant questions.

Physical examination and laboratory study –

The detailed interview provides clues to the tentative diagnosis of disease. Relevant physical examination will provide further evidence to diagnosis. Necessary laboratory investigations will provide supportive evidence and in certain cases firm evidence for final diagnosis.

Data analysis and totality –

After data collection, the next step is to put it in proper perspective so as to arrive at totality. A term in

Homoeopathy which can be equated with the term diagnosis in conventional medicine. Totality denotes

perceiving patient as a whole and its individuality.

Totality has following important aspects –

1. Locations and the processes (pathophysiology)
2. General symptoms
3. Mental state
4. Characteristic particulars

Evaluation of symptoms –

From such a mass of symptom one has to select important characteristic symptom which will portray a patient as a distinct than others suffering from same disease.

The first point to remember is that the totality should have a match in the material medica. Therefore, a consideration as to what is available in the material medica is important. The study of material medica should go hand in hand with the study of the cases.

A grand rule to be observed is that the generals – mentals as well as physicals – are of primary importance. Between the two, mental symptoms or the mental state forms the core of the totality is more important, provided our assessment regarding the mental state is right. Since this assessment is difficult we prefer to start with physicals. Occasionally it so happens that the mental state point to one remedy while the physicals belong to some other remedy. In such cases discretion is necessary in deciding as to the authenticity of the symptoms in the patient as well as in the drugs.

Mental state, if we are able to perceive, will be more helpful than the isolated mental symptoms.

1. Among physical generals following order can be put in decreasing order of importance. Care must be taken that intensity is also considered while evaluating these.

– Causative modality

–  Time modality

– Thermal reactions

– Alternations and concomitants – Discharges

– The effect of physiological processes – sex

– Food

– Motions, positions, and other actions

– physical factors

– sides of the body and direction

– general sensations

– Age, sex,epoch

– Pathophysiological considerations

– Physiognomy

2. If the case presents very few generals or weak generals, we should pay attention to particular and especially the characteristic particulars which we have already alluded to. Care must be taken to see that the remedy also corresponds at a general level otherwise such ‘keynote’ prescriptions, as they are called, are sure to end in failures. Location can also be included in characteristic particulars.

We should not overlook the old symptoms. At times they are characteristic and indicate or support our prescription.

3. Lastly the mental state or mental symptoms are to be considered.

Suggested Further reading for case taking and Homoeopathic philosophy –

The term Homoeopathic philosophy encompasses writings of number of Homoeopathic physicians to demonstrate Homoeopathy as the logical and scientific approach in practice of medicine. While reading one gets stuck up with arduous journey of Homoeopathy and efforts of earlier stalwarts in Homoeopathy. Read in the following order when time permits. It may take a few years to understand the logical mind of Dr. Samuel Hahnemann. That is the reason we have kept ” Organon of Medicine ” the original source book as the last in the list of books.

1. The Genius of Homoeopathy – Stuart Close
2. Studies in the Philosophy of Healing – C. M. Boger
3. Principles and Practice of Homoeopathy – M. L. Dhawale
4. Homoeopathy – The Science of Therapeutics – Carroll Dunham
5. Lectures on Homoeopathic Philosophy – J. T. Kent
6. The Lesser Writings – J. T. Kent
7. The lesser Writings – C. M. E. Boenninghausen
8. Organon of Medicine – Dr. Samuel Hahnemann
9. The Lesser Writings – Dr. Samuel Hahnemann