How to approach homeopathic case

Taking a homeopathic case is an art and every homeopathic physician must learn it. As our mentor Hahnemann stated ‘a well taken case is half cured.’ Your case taking starts as soon as the patient takes an appointment on the phone and or as soon as he enters your clinic. So, the physician must be vigilant enough in his observation of the patient. When we should thoroughly observe the patient before we starts taking case. For an example when patient enter in our OPD we should observe the way of making his entrance, i.e. is he/she enter fast or slow, looks timid or bold? Does he/she look anxious?  How was his/her expression on face? All these little things matter in homeopathic case taking. They fill missing gaps in case. Mostly they are helping in construct the constitution of the patient.

·       Before taking a case one must collect preliminary data & basic information from the patient. Preliminary data are very useful in case study & in medico legal information. This includes —

1.    Name of the patient

2.    Age & Sex of the patient

3.    Occupation & Qualification of the patient

4.    Relationship status of the patient

5.    Religion of the patient

6.    Address & Contact number of the patient

·       After basic information from patient physician must ask for chief complain.  It is main part of the case taking so it must be noted very well. Duration of the chief complains must be note, by which we can one can know how long patient did suffer. A physician must ask how was onset of the complain, which was gradual or sudden. If complain includes pain then one must ask for location of pain, duration of pain, how long pain remains, how the pain comes and goes, what is character of pain, extension of pain, how does it decrease & increase in intensity. If it has any particular side affection then it must be noted and also where did it started first left or right or it was from left to right or right to left. For a complete symptom we must includes modifying factors i.e. how complain aggravates and how it is ameliorates. A physician must investigate patient locally and systemically for finding any physical or significant symptoms. From chief complain physician must rule out for probable diagnosis of the case. History will also rule out other disease in case if there is any.

·       Now comes part when physician notes about vital status of the patient. This includes—

1. Blood pressure

2. Pulse

3. Temperature

4. Respiratory rate

5. Urine output

These are very important in all cases especially in acute one. This will help in determine condition of the patient.

·       Past history is important in homeopathic case taking. This includes any major illness which patient has suffered in the past. In past history physician should try to elicit any major illness where in patient was not well after suffering from it. For instance, never well since typhoid, malarial fever etc. Past history does not mean only certain disease condition, but it also includes any trauma it maybe mental or physical, accidents, surgery or any laser surgery etc. Try to find the journey of disease in chronological order and the ascending nature of the disease layer wise.

·       Does patient have any family history of any disease? This will give idea about any hereditary disease which runs in family.

·       Personal history will give many characteristic symptoms which is helpful in erecting totality of symptoms. This includes—

1.    Appetite:Ask Patient about his food habits; does it increased or decreased? Does patient is OK with cold or warm food? Can he stay hungry? If he cannot bear hunger then ask when. Does he prefer veg or non-veg? Which drinks he likes? Soft drinks, cold drinks, juices, lemonades? Ask what he desire for & aversion to. Any food or drinks he likes.

2.    Thirst:How much water you drink in a whole day? Do you feel thirsty or it is your habits? Does your mouth, tongue or throat get dry? Do you prefer warm or cold water? Do you often drink water or prefer to drink water at long time? Approx how much do you drink water at a time?

3.    Tongue:Observe patient’s tongue is it moist, dry, flabby, any imprint of teeth, coated, cracked, mapped (geographical), dirty.

4.    Thermal:Ask patient what he can tolerate more heat or cold? Does he want fan or A.C. on or OK without it? Does he the one who take sweater first in family?

5.    Stool & Urine:Does it have any particular or specific symptoms in it?

6.    Sleep:How much he sleeps? Is it refreshing? In which position you sleep? Any habits of snoring, salivation from mouth, nocturnal enuresis?  Is sound or alert?

7.    Dreams:Do you remember any dreams? If yes then what is it about? How does it affect you?

8.    Perspiration:How much you perspire? Which part of body? When? Is it offensive? Does it cause stains on clothes?

9.    Addictions:Which addiction does patient have & since when? Addiction may be is the maintaining cause of the disease e.g. smoking for respiratory complains.

10.                       Speech:Hasty & hurried? Slow? Loud? Low? Jerky? Stammering? Nervous? Confused? Excited?

11.                       Milestones:Teething, walking, speaking etc.

·       Appearance of patient is really matter in homeopathic case taking. This includes—

1.    Built of body

2.    Body structure

3.    Posture

4.    Hair & face

5.    Complexion

6.    Discoloration or pigmentation

7.    Way of clothing

·       Drug history:Ask patient if he is taking any medication. Certain patient has allergy towards medicines. If he is taking medicines then ask him what for he is taking medicines & since when he started to take. In this one should think about any chronic side effect of the medication if patient is taking for long periods as presenting complaints.

·       Gynecological and obstetric history:Ask her about menarche was on normal age or early or delayed. Take full menstrual history. Before, during, after menses any characteristic complaints like backache, weakness, irritation etc. In menopausal women ask the time of menopause normal-early-delayed. Ask any other common or uncommon gynecological complains like leucorrhea etc. Was there any habitual abortion or miscarriages? Full gynecological & obstetric history requires in female cases.

·       Mental and life span:This will make patient individual one. Try to get familiar with patient. Get in to conversation with patient in deep like his hobbies, will, fear, anger, reaction, emotions, memory, intellectual level etc.

After note down all symptoms homoeopathic physician must erect totality of symptoms. Try to find group of medicines which suits in case by aid of repertory. And final similimum medicine is decided by materia medica.

So this was regarding homeopathic case taking.