We enter our world of medical practice after completing our medical degree &/or PG degree. Then, by the time our memory & skills should have some boost up by reading about history taking and Art of case taking regularly. Otherwise some important points are forgotten to be taken note of. And the important tools for cure are missed forever. Reading about case taking regularly acts as reminder to us. A well taken case is equal to more than half way to cure.
Hurry or indifference never helps in medical practice. At first we have to diagnose the case to assess the pathological stage and prognosis later. Diagnosis also helps in proper management or tmely referral for suitable treatment. For diagnosis we have to go through the books of clinical medicine, clinical surgery, clinical Gynae & Obs., clinical pediatrics. Finally, for the Homoeopathic prescribing we must become the expert of Art of homoeopathic case taking. He we must be unbiased, alert, artistically expert to deal with human minds and diligent. Because we must not miss any uncommon peculiar characteristic symptom to be successful to achieve complete cure. So we must go through the case taking chapters of the books of Homoeopathic philosophy, like Organon of Medicine(aphorism 83-104), Kent's, Robert's, Stuart Close's philosophy, Gibson Miller, Elizabeth Wright, E.B. Nash, Pierre Schmidt's Art of Casetaking & Interrogation, etc. so that we can recollect them continuously as needed at clinic or bedside. Here is a case taking format as an example below. Before going through it we should remember the warning Dr. Samuel Hahnemann had given at very beginning of Homoeopathy in preface to the first edition of Organon of Medicine: "I must warn the reader that indolence, love of ease and obstinacy preclude effective service at the altar of truth, and only freedom from prejudice and untiring zeal qualify for the most sacred of all human occupations, the practice of the true system of medicine. .." Case taking format : Patient's Name: Age: Sex: Occupation: Previous occupation if any: Educational Qualification: Address: Quality of residence and its locality: Presenting complaints: (clarify each symptoms in following points: a. Location of the symptom b. Sensation (if any) c. Modalities (amelioration & aggravation) d. Concomitant symptoms present with presenting complaint but seemed to be unrelated (peculiar) ) Past history of illnesses: (any mention worthy illness/ disease, hospital stay, even any skin symptoms, any discharge from any mucus lined outlet, menstrual irregularities etc. preferably chronologically mentioned) Family history of any major diseases: General amelioration and aggravation incidences regarding body feelings: (in respect of different weather, season, positions of body, motion or rest, steong odour, noise, light etc. anything mentionable.) Thermal reaction: (whether feels discomfort more in heat or cold (hot or chilly patient) Appetite:(less/normal/much, whether can tolerate hunger or not, likes hot or cooled food & drinks, etc) Desire , Aversion & Intolerance of food and drink : Sleep quality and timings and position & dreams during sleep: Hobby or leisure engagement: Mind symptoms: Conscience, patience, introverted or extroverted, miser, indifferent, fastidious, systematic, lazy, industrious, reaction in anger, grief and consolation, will, despair if any, desire to die, haughty or polite, hurried or slow, Memory: forgetful about what kind of topics, Intelligence, joy, previous grief, humiliation, hesitation, hatred, desire to be alone or desire company, talkative, fear, delusion etc any significant symptoms of the person. Relation with neighbours, with persons at work place, at home. Sweat: (its character, does it stains clothes etc) Stool: Urine and urination: Menstrual symptoms: Sexual symptoms: (must be asked in second consultation or later when suitable) Thanks to all of you.
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AuthorDr. Anindya Das, B.H.M.S. Archives
October 2018
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