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Friday, August 18, 2006

CASE TAKING FOR ADULTS


NAME :-AGE :-
SEX :- Male /Female
ADDRESS :-
E-mail ADDRESS :-
OCCUPATION :-
1.CHIEF COMPLAINTS :-PRESENT HISTORY
All the complaints that you, the patient, are experiencing including their duration and sequence. Please write down "all" the complaints that you have.
Elaborate each symptom as to:
Cause”
Character
Location
Extension
Radiation of pain or sensation
Associated concomitants
Aggravation & amelioration: regarding
a)Time
b)Temperature & weather
c)Bathing
d)Rest or motion
e)Position
f)External stimuli
g)Eating etc.
h)Before or after
i)Menses
j)Coition
k)Defecation etc.
2.APPEARANCE
:- Thin, Obese, Tall, Short, Fair, Dark.
TONGUE:(its appearance.if coated,the colour & nature of coating)
THROAT:(appearance,conditions of tonsils & uvula)
SWALLOWING:(liquids,solids or empty)
3.SYMPTOMS OF SPECIAL SENSES:
a)eyes & vision
b)ears & hearing
c)nose & smell
d)mouth & taste
e)skin & touch
4.APPETITE
:-Normal,decreased or increased) Any trouble before or after eating in general eg pain, burning,heaviness,sleepiness,distension etc,from any particular food,article.)
LIKING for hot or cold
5.THIRST
:- Medium, Increased or decreased.:- a) How many glasses per day ? b) Cold / Normal water.?
6.DESIRES
:- a) Taste of food you like ? ( i.e. Spicy, Sour, Sweet, Salty etc. b) Any specific craving for a particular food item ?
7.AVERSION
:- Any food item that you don’t like or the one that aggravates your complaints.
8.FLATULENCE-a)bloating of abdomen,when? b)passing of gas up or down gives relief
9.CONSTIPATION:
a)Whether unsuccessful urging or no desire?
b)haemorrhoids(blind or beeding)
c)fissures
10.STOOL
:- a) Satisfied /unsatisfied ? b) Constipation / Loose-motions.?
11.URINE:
a)increased during day & night
b)burning in urine
c)incontinence of urine
PAIN:- character,before,during or after
12.PERSPIRATION
:- a) Increased on any particular part of your body.? b) Offensive c) Stains or not.?d)whether feels weak or no effect?
13.SLEEP:-
a)character b)posture during sleep{back sides abdomen etc.}
c)whether refreshed or tired after sleep d) whether aggr or amel during or after
14.DREAMS:-
Nature & character :- {confused,pleasnt,horrible,frightful,disgusting,disagreeable,vivid etc.}
15.PAST HISTORY
:- Have you suffered from any major illness in the past like Malaria Typhoid, Tuberculosis, Hepatitis, Skin problems etc or any Surgery undertaken.?
16.FAMILY HISTORY
:- Any history of Hypertension, Diabetes, Tuberculosis, Heart problems, Cancer etc. in the family.?
17.ADDICTIONS
:- If any ?
18.ANY COMPLAINT IN LIMBS & JOINTS
19.ANY SKIN ERUPTIONS
20.TENDENCY:
a)to catch cold{when & how}
b)to suppurate easily
c)to bleed
d)to faint{under what circumstances}
e)to tumours,cysts,polyps,warts,moles
to certain diseases
21.GENERAL REACTIONS aggravations or ameliorations as a whole
a)warmth,warmth of bed;warm room (hot)
b)cold,cold air,cold wind (chilly)
c)hot & cold;wet & dry weather changes:
d)thunderstorms or storm (before,during & after)
e)open air or closed rooms,changes from one to another
f)hot sun,wind,fog,snow
g)stuffy crowded places,draughts,heat of stove,uncovering
h)rest & motions(slow,rapid,ascending or descending;on first motion;after moving while,while moving,after moving,traveling in car,bus train sea,air etc
i)Position:
standing,sitting,stiooping,rising on painful side;back,sides,abdomen,head high or low,leaning head backward,forward,sidewise,,upwards
closing or opening eyes
any unusual position
j)External stimuli:
touch
pressure & rubbing
constriction(clothing etc.)
light,noise,music,smell
jar,riding,stepping
k)Eating & drinking(before,during or after)
fasting
any particular item of food
l)Emotions:anxiety,grief,joy etc
before important engagements
m)Exertions:physical & mental
n)company,crowds,loneliness etc.
o)Time,hr,day,night or midnight
22.PERIODICITY-daily,alt days,wkly,yearly etc.
23. FOR FEMALES ONLY
1) Menstrual History :-
a) Menstrual flow for how many days and after how many days?
b) Any associated complaints with menses.?
c) If menopause :- Any complaints before/during and after menopause. ?
2) Leucorrhea if present ?
a) Colour, Stains or not, offensive or any peculiar smell.
b)acrid or bland
c)whether feels hot to parts
d) circumstances under which more or less {eg lying,walking,exertion,menses,day,night,mor,night etc.}
3) Obstetric History :-
a) No. of children - Normal / Caesarian delivery.?
b) Abortions – if yes specify which month.?
c) Any complaints during / after pregnancy.?
4)Sexual sphere:-
a)sexual desire-normal,increased,decreased or suppressed
b)any aversion to sex or coition
24.FOR MALES ONLY
Premature ejaculation, impotence ,wet dreams, relaxation of genitals, masturbation.
CLIMATE
:-Preferred hot /coldBATH
:-Warm /cold.LIKES
:- Fan / ACMIND

25. MENTAL
pl note: for the patient to detail: Homeopathy is a holistic system of medicine and is most useful if information about the whole person is generously supplied, so please give information regarding yourself as to :
1) What bothers you ?
2) Any FEARS or PHOBIAS. ?
3) Anxieties , Irritability , Imaginations ?
4) Emotional state — Brooding , crying, Suicidal etc. ?
5) Likes company or loner and why ?
6) Dreams—-if you remember any particular dream or any dream you have seen repeatedly.?
7) Do you cry easily?
8) Does music,kind words of others,grief,fight of others make you cry?
9) Do you get offended easily or can take criticism from others or do you feel hurt or insulted easily?
10)When you are upset, if you are consoled by your family or friends, how do you take it i.e does sympathizing help you or make matters worse?
11)Do you speak out your emotions,worries etc or pent them inside you and later brood over it?
12)Do you feel anxious/ apprehensive before exams,meetings,public speaking, any stress situations?
13)Are you a perfectionist—–being very particuliar about cleaniness, puntuality,fastidious and even finiky?
14)Is there any grief that you have felt it or any greastest joy you have experienced in life(please give in detail)?
15)Do you like music or not,or does it affect you by any chance?
For homeopathic doctors pl note that the mental symptoms can be classified into a) WILL b) UNDERSTANDING c) MEMORY I am elaborating the full range of mental symptoms in these three groups, search for these symptoms,if patient has.
A WILL
1. Anxious or fearful-animals,being alone,darkness,death,disease,health,robbers,future,noises
2. Indifferent- to business,husband,relations etc.,
loathing of life;suicidal
haqte
greedy,haughty
doubtful,suspicious(for what)
wants company or loneliness
irritable,quarrelsome,offended easily
depressed,sad,brooding
impatient,hurried,
jealous
wants sympathy or hates
changeabl;e,indecisive
shy,timid,cowardly
obstinate,affectionate
silent or talkative
mild,yielding,gentle
tidy or untidy
reaction to contradictions
hopeful or hopeless
cheerful,happy,calm
B UNDERSTANDING
Delusions,hallucinations,illusions
Absorbed
Clairvoyance
Confusion
Dullness of comprehension
Comprehension-difficult or easy
Ectasy
Excitements
Imbecility
Loss of time sense
C. MEMORY
Concentration
Absent minded
Errors in answers
Mistakes in writing & speech
Disordedrs of speech
26.TREATMENT TAKEN SO FAR
27.PHYSICAL EXAMINATION & PATHOLOGICAL FINDINGS
28.LABORATORY FINDINGS

FOR THE PATIENTS pl NOTE
We weigh the symptoms in order of their importance and then begin looking at the remedies. When we find the one that best matches the totality of your symptoms i.e. "THE WHOLE YOU" , then we prescribe it.
Well , I would like to see or search for strange, rare, peculiar symptoms because it makes my job easier. So please specify if you have any.

Dr prabhat tandon

1 comment:

pravin said...

A Good Case Taking Formate..