CASE TAKING

(TAKING OF A CASE)

By Dr.S.Manilal.MD(Hom).MBA

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 Introduction
The mission of a physician is to help the
suffering humanity by curing the diseases.
Cure begins with the process of case
taking.
Case taking is the essential foundation of
treatment.
Sound case taking assist the physician to
plan the whole course of the treatment.
Good case taking helps the patient to
realise his own problem.
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According to Dr.Elizabeth Wright
“A well taken case is half cured”
For proper case taking the physician should know:

What is a case?
Role of the physician.
About the patient.

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 What is a case?
Case is not merely a group of symptoms.
It is an illustration of disease, an event and a
change in the whole person from his original
Health to his present sickness.
It comprises of all the expression in the mental
and physical plane.
It forms the portrait of disease.

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 PHYSICIAN
He is the master of the show.
A physician should be a great learner.
He should learn from experience.
The desire to learn and hardwork are the tools of
the learner.
A physician should know the five ‘D’s of health.
Disease, Discomfort, Disability, Dissatisfaction
and Death.

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- Should have the knowledge of disease and its
indication.
- Knowledge of medicinal powers.
- Should know what is curative in medicine.
- Should know what is to be cured in the disease.
- Knowledge of application of medicinal knowledge
to disease knowledge.
- Choice of the remedy.
- Proper dose
- Repetition of dose

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- A physician should know the obstacles to
recovery and their removal.
- Should know the cause of the disease.
 Exciting cause – Acute disease.
 Fundamental cause- chronic disease.
- Should be an unprejudiced observer and able to
perceive the portrait of the disease.

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 PATIENT
• Victim of the adverse environment
• He needs help
• Not capable of working efficiently
• Who has lost the equilibrium of functioning
Expectations
Expect the physician to listen to him.
Physician should have professional competence
in medical science and technology
Knowledge of recent advancement in medical
science.

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 Definition of Case taking
• Case taking is a unique art of getting into
conversation, observation and collecting
information from the patient as well as from
the bysatanders to define the patient as a
person and the disease.

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 Objectives of case taking
To understand the patient in his
surrounding. (family, work and society)
To define the problem of the person.
To understand the disease of the individual
with its common and characteristic
symptoms.
To attempt problem resolution and effective
counselling if needed.

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To manage the case – auxiliary, general
and specific.
To help the patient to realise his problem.
To help the patient ventilate his problems.
To find out the constitutional, intercurrent,
and acute totality so that respective
remedies can be selected

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 Hahnemann’s instructions of Casetaking
In his book “Medicine of experience” 1805,
he described the method of investigation of
a sick man .He unfolded the methods of
case taking in all editions of Organon of
Medicine.The instructions are given in
Aphorism 83 to 104.
• It is the duty of the physician to implement
it.

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 Case taking chart

Aphorism 83 Aphorism 84 Aphorism 85

Physician- Recording New symptom
1.Free from Of fresh line
Prejudice symptoms
2.Sound
senses
3. Attentive

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Aph.No.86 Aph.No.87 Aph.No.88
Physicians Details of Use of general
observation symptom expression

Aph.No.89 Aph.No.90 Aph.No.91

Precise and Observation Past treatment
special & recording

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Aph.No.92 Aph.No.93 Aph.No.94
Recording Private ? Investigation of
Acute Maintaining
disease cause

Aph.No.95 Aph.No.96 Aph.No.97

Recording of Recording of Recording of
long suffering Hypochondric Indolent case
case
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 Aph.No.98 Aph.No.99 Aph.No.100/101/102
Record only Recording Investigation of the
patients acute case is Epidemic disease in
language easy particular

Aph.No.103 Aph.No.104
Investigation Utility of noting down in writing the
of psora picture of the disease for the
purpose of curing in the progress
of the treatment 16
 Qualities of a Physician
For proper case taking each case of
disease should be individualised.
Each case is unique
The concept of individualisation hold the
key both in health and disease.
Individual should be studied in his own
environment ie., family, work and society.
For dealing in this unique situation the
physician should have the following
qualities
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i. Freedom from prejudice
Should be free from all prejudices.
Should not have any preconceived ideas
and concept.
If prejudiced his observations will have
three possibilities.
a) Correct observation
b) Malobservation
c) Wrong observation

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ii. Sound senses
> Duty of the physician is to note the
change
from healthy condition to the diseased
condition.
> To get good judgement of signs and
symptoms, physician should have good
health of mind and body.
> Sound sense means senses capable of
noticing a change however minor it may
be.
> Senses can be called sound only if the
mind can employ them to their best
capacity.
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> A physician’s senses can be called sound only
if he is capable of utililizing them in
undisturbed, uninterrupted and unbiased way.
> Soundness of senses also depends on the
sensibility and commitment of the physician to
the profession.
iii. Attention in Observing:
While recording the symptoms, physisican
must be an attentive observer.
He should have his eyes on each and every
expression.
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iv. Fidelity in tracing the picture of the
disease.
o Physician should be faithfull and loyal in
recording the deviation from health with
firm adherence to the principles of
homoeopathy.
o Physician should be able to translate his
observation into words by using the most
appropriate expressions.

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o Physician who is vague, impatient or
insensitive cannot show his exactness in
eliciting, detecting and forming a true
portrait of disease.

o Notation should be in the patient’s own

words.

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Hahnemann gives clear instructions regarding
the clinical interview and how to record
symptoms

 The physician should allow the patient to

narrate whatever he wants to tell about the
disease and himself.
 Physician should not interrupt patients.
 Physician should involve himself in active
listening.
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 Recording shall be done in the patient’s
language only.
 Role of bystanders is also very significant
when the patient is a child or unconcious
or unable to communicate due to other
reasons.
 The physician should advise the patient and
bystanders to narrate the history properly and
slowly and he has to note down all the important
parts of narration.

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 New Symptoms
Add the additions to any one symptoms
which have been mentioned vaguely
previously.

Physician should record each and every

symptom as a complete symptom.

Each and every new symptoms mentioned

by the patient or his friend should be
written separately one below the other.
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Complete symptom is the one which fullfills
the duration, onset, causation, location
sensation, extension modality and
concomittent.

The physician should be a keen observer.

By that he obtains more precious

information.

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Physician should not ask direct questions,
leading questions, multiple choice
questions.
Direct questions : The questions which can
be answered Yes or No.
Leading questions – The question which
suggests its answers.
Multiple choice questions – The questions
that give the patient a chance to select
between two things or more.

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 Use of General expressions
• After recording the signs and symptoms he
should further investigate the functioning of
the body and mind .
• Should enquire into various bodily
functions, emotions and intellect.
• He has to make a note of mental and
physical generals.
• This part of the investigation is very
important in the totality.
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• Should use only general questions and
expressions.
• Give the patient time to think and make him
narrate the details about his constitution.
• In female the details of puberty,
mensturation, pregnancy, delivery,
lactation, menopause as applicable to the
age should be noted.

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 Precise and Special questions

• After recording of symptoms of patient and

bystanders, a picture of the disease should
emerge. If the physician still feels that he
should get more information he has the
liberty to ask more precise, more special
questions to complete the picture.

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To quote Hahnemann Eg:
• How often his bowels are moved?
• What is the exact characters of the stool?
• What did the patient vomit?
• What is the colour of urine?
• How does he sleep whether to right or left?

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 Observation of the Physician
The physician should observe the patient.
Make note the patients behaviour.
Facial expressions, dullness, way of
answering, other details of physical
examination. Physician has to record it.

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Then he should compare to note the
difference of this findings with the
symptoms existed during his healthy state
to find whether the findings are a part of
the disease or part of his constitution. This
helps to understand the true concomittants
of the disease.

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Fundamental idea about the Original form of disease

• Should try to trace the original unmodified

pictures of the disease in all chronic cases.
• Should find out whether he is under
treatment, what type of treatment,
suppressive – palliative.
• If under treatment, the present picture will
be a combined picture of disease and drugs.

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• Has to elicit the actual picture before treatment.
• If the patient cannot remember advise to
discontinue the treatment. Give placebo in
between. Then record the case when the pure
picture is emerged.

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 Recording of Acute cases
In the disease of rapid course, the
physician should be satisfied with picture
available on first enquiry and on
observations.

Some times the rapid course can be the

effect of some injurious drugs. Whatever
the cause should not waste time for
unnecessary details.

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Should erect a totality of the combined
effect of medicinal and original disease.
The product of original and medicinal
disease is called Conjoint malady

The physician should form the picture of

conjoint malady and prescribe suitable
homoeopathic remedy otherwise it will
become fatal.

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 Private questioning
• In most cases the patient comes out with
all the details without hesitation.
• Sometimes need skillfull questioning. If the
physician assures confidentiality of the
data the patient reveals the symptoms
• In these conditions the physician should
have a rapport with the patient.
• Majority patients donot like to share things
which they think are disgraceful. But this
information has great value in working out
a case.
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 Maintaining cause
• In chronic cases the physician should enquire
about the
• Occupation
• Mode of living
• Diet
• Domestic situation etc
• An investigation carefully done regarding the man
and his environment ie., family, work and society
will deliver the exiciting and maintaining cause.
This is important in understanding the disease and
health promotion. Removal of maintaining cause
will help the recovery of the patient.
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 Recording of Long suffering
While recording of long sufferings, all
signs and symptoms of the above
mentioned as well as the most minute
particulars must be properly recorded.
In case of chronic diseases due to long
duration of sensation and complaints,
patient thinks that a few symptoms are part
and parcel of their general and normal
functioning.

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 Patient donot share this symptoms with
the physician. These symptoms are
called Accessary symptoms. Eg:
 loose stool in the morning.
 Feeling exhausted after sleep etc.
The reason for not mentioning the accessary
symptoms to the physicians
1. Patient is used to the symptom for a long
time so they consider them as part of
their health.

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2. They think these symptoms as minor or
unsignificant things.
3. They think that these symptoms do not
have any connection with the main
complaint.
These symptoms are very important for
making totality, selection of remedy and for
Finalising the prescription

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 Hypochondriac and Hypersensitive
patients
Physician should be alert about the
hypochondriac and hypersensitive patients.
Hypochondriac are patients who have a
morbid anxiety about their health.
They present imaginary illness.
Complaints keep changing with regard to
description severity and location.

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Disease may be the result of nervousness
or imaginary fears.
Earlier belief was that the complaints seat
in abdomen so the name hypochondriac.
Hypersensitive patients are patients who
exaggerate their sufferings.
They present the sickness in very dramatic
and descriptive way.
Hypersensitive patients cannot tolerate a
little suffering or pain.
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The difference between Hypochindriac and
Hypersensitive patients are
Former imagines the complaints, later
overstates or intensifies the complaints.
Both want special attention of the physician.
Both differ from insane and fiegners.

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 Case taking of patient who are Indolent
Some patients donot take much interest in
describing their ailments.

The reason can be

1. Lack of interest or Laziness
2. False modesty
3. Mildness
4. Weakness of mind or lacking of
capacity to describe.

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5. Sometimes patients will not mention any
other symptoms. Only the chief
complaint. This is because he thinks the
physician’s attention will be diverted or
divided.

6. Patients do not understand the need for

telling each and every symptom

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 Record only in Patient language
A physician should give more importance to
the patient’s description of his suffering
especially in chronic disease because

• He alone can describe his complaints

accurately and exactly
• We can understand the intensity of the
symptoms, modalities and concomittnats
only from him.

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• Expressions and feelings are best known
to him.

• When others present, the word meaning

and description tend to change.
For complete and true investigation of
chronic disease need
• Especial circumspection – Should carefully
observe and take note of all things peculiar
to health and disease

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• Tact -He should be skillfull in managing the
feeling of the patient and doing the best in the
circumstance.
• Knowledge of Human Nature - Should be
aware of the feelings and reactions in various
conditions and the needs of the mind at
various stages.

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• Caution in conducting the inquiry – The
enquiry should be made with great care
and respect to human life. Attitude and
words should not be unpleasing to the
patient.

• Patience – The physician’s patience gives

great relief and satisfaction to the patient.
This increases the confidence of the
patient. This encourage the patient to
narrate the story of his sickness.
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 Case taking in acute disease
• The investigation of acute disease is much
more easy compared to chronic diseases.
The reason is that
• All changes in the health are fresh in the
memory of the patient.
• The symptoms of the disease are more
prominent.

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• Due to recent origin and nature of the
disease the symptoms comes to the notice
of the physician without much difficulty.

• In acute case also physician has to

construct totality. It is not difficult because
the patient narrates the symptoms easily
without asking.

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Investigation of the epidemic,sporadic diseases
• In epidemic and sporadic diseases physician
should study the disease carefully.
• Should examine it properly without being
biased by earlier experiences.
• Should treat each disease as a unique
phenomenon.
• There will be some similarity in presentation
and name but there will be always an
individual characteristic.
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• Even from same causation because of
difference in constitution of the persons the
expressions will be different.
• The epidemics caused by the same source
will have similar common symptoms.
• In epidemic cases the totality of the
disease is known only after the physician
study several cases.
• The study of single case will provide only
partial picture of the disease.
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• An experienced physician who observes
carefully can get complete picture or portrait
by studying a single case of epidemic.
• The experienced physician can prescribe
suitable homoeopathic remedy even after
studying single or few cases.
• Physician will get a clear and complete
picture of the disease when he has studied
several cases.
• Should write symptoms under general
symptoms and characteristic particulars.
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This forms the totality of epidemic.
• To know complete picture of an epidemic
physician should study its symptoms in
several patients of different constitution.
• Medicine selected on the basis of this final
totality is called Genus Epidemicus.
• This medicine can be used to treat the
epidemic and also as Preventive medicine.

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 Antimiasmatic medicine
• The chronic miasmatic expression (psora) cannot
be studied in a single person.
• To get a clear picture of the fundamental miasm
(psora) several persons should be studied
separately.
• Partial picture when joined logically will get a
complete picture of the miasmatic chronic disease.
• On the basis of this final complete picture an
antimiasmatic (especially antipsoric can be
selected.
• This medicine will help several patient suffering
from this miasmatic disease.
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 Utility in writing down each case and
Dr.Hahnemann’s suggestion for better result

• The physician who has all the relevant

datas by doing detailed investigations and
listening to the patient carefully , he forms
the portrait of the disease. The most
important and difficult part of the treatment
is completed by this stage.

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 Further steps for better result
• He should make the totality by picking out
all characteristic symptoms.
• Should select a Homoeopathy remedy
which covers the most ie., similimum.
• When the patient reports back after the
stipulate time the physician should acertain
the effect of the similimum by studying the
change in the state of mind and body.

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• At each follow up look at the case as a
fresh one.
• Find out the changes in the symptom
reported during the previous visit, strike out
the symptoms which are relieved.
• He can know what symptoms still remains.
• Should find out any new symptoms
developed during the course of the
treatment.

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 Outline of Taking the Case
1. The patient’s story.
2. Modalities as applied to each of the above
symptoms in the following order.
i) Causes
ii) Prodrome, onset, pace, sequence,
duration.
iii) Character, location, laterality, extension
and radiation of pain or sensations.
iv) Concomitants and alternations.
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v) Aggravation or amelioration.
a) Time, Periodicity, seasons, moon phases.
b) Temperature and weather.
c) Bathing, local applications.
d) Rest or motion, car and sea sickness.
e) Position: Standing, sitting, stooping unusual
position such as knee chest etc
f) External stimuli
g) Eating In general
h) Thirst
i) Sleep
j) Menses
k) Sweat
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l) Other discharges
m) Emotions
n) Strange, rear and peculiar symptoms.

3. The patient as a whole: Mental generals,

physical generals.
Physical Generals
a. The constitutional type of the patient
b. Ailments from emotions, suppressions, exposure
to weather conditions.
c. Menses, date of establishment, regularity,
duration, color, consistency, odor, amount,
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 Clots, membrane, pain, concomitants,
aggravation or amelioration before,
during or after, menopause.

d. Other discharges, cause, color,

consistency, odor, acrid or bland,
symptoms from suppression of
,symptoms alternating with hot or cold,
partial discharges as of sweat, laterality,
better or worse from discharges.

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e. Sleep, better or worse from, position in,
aggravation after, difficulty in getting to
sleep, waking frequently of early, at what
hour, somnabulism, talking in
sleep,dreams, restless during.
f. Restlessness, prostration, weakness,
trembling, chill, fever etc.
g. Aggravations and ameliorations applying
to patient as a whole.

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h. Objective symptoms such as redness of
orifices, superfluous hair, applying to the
patient as a whole.
i. Pathology which applies to the patient as
a whole, such as tendency tumors, wens,
cysts, polyps, warts, moles, individual and
family tendency to certain diseases or
weakness of specific organs or tissues,
frequency of catching a cold.

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Mental Generals:
i) Will: Loves, hates and emotions
ii) Understanding
iii) Intellect
4. Quick review of the condition of every
system and organ, beginning with head and
following the order in Kent’s repertory.
5. Past history of patient
6. Treatment history
7. Family history
8. Physical examination and laboratory tests.
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 SUMMARY
It is neither possible nor desirable to
obtain all clinical information from every
patient while taking a case on first
reporting of the patient.
Case taking ability improves with
experience, and there are important
humanistic elements in obtaining clinical
information, which are artful.

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Case taking can be both taught and
learned. It requires both knowledge and
skill, and these skills can be refined only
through practice.
Three important aspects of the case
taking ie., conversing with patient and
obtaining a history, physical examination
and laboratory investigations.

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Conversing with the patient and obtaining a
history
General Principles while conversing:
a) Avoid careless, haphazard conversation
and give a thought to everything that the
patient narrates.
b) Be certain that the patient understands
your question and you understand the
patient’s answer as well as queries.
c) Employ simple expressions that are
easily understood.
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d) Never frighten the patient. Foster
optimism, self confidence and
security.This leads to confidence in
future.
e) By thoughtfulness, thoroughness and
personal dignity, enhance the patient’s
confidence.
f) Appropriate humor can be a powerful tool
of communication.

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 General Instructions while obtaining the History:
a) Make the patient comfortable, both
physically and mentally.
b) Make sure the patient knows you and your
role.
c) Make certain that there is a two-way
communication.

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d) Interview the patient alone. The relatives
or attendants should be called later at an
appropriate time.
e) Have eye contact, listen properly, give
adequate time and avoid writing detailed
notes while the patient is talking.
f) Let the patient have freedom of enough
time to express in his own terms without
interruption.
g) If the patient is severely ill, invalid or
emotionally upset, inquire about the
present illness first.
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h) If a particular line of questioning makes
the patient uncomfortable, embarassed or
anxious, move on to another topic without
pressing too far at the time of initial
encounter.
i) Unnecessary probing on the part of the
physician should be avoided.

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 Physical examination
It requires thoroughness in routine
examination, skill in techniques and
understanding the sequential logic used in
the examining process.
Finding by Physical examination.
a. Vital signs
b. Evidence of severity of illness
c. General appearance
d. Palpable lesions
e. Respiratory difficulty

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f. Murmurs, bruits, friction rubs and bowel
sounds.
g. Neuralgic signs
• Laboratory Investigations:
Use laboratory data in patient care has
become an essential skill required of
every physician. Effective use of a
laboratory should be developed as
carefully as other clinical skills required in
day-to-day practice.
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Importance of Laboratory Tests
a. It helps in screening
b. It may be used in establishing the
presence of a suspected illness.
c. It may be used to exclude the presence
of disease.
d. It often provides a useful initial measure
of severity of disease process present.
e. It also helps in selecting and monitoring
therapy by providing information about
the amount and rate of changes at tissue
level.
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CASE TAKING IN DIFFERENT TYPES OF CASES
Acute Cases: Acute diseases are defined as
diseases which begin suddenly, progress
faster, run a definite course and finally end
either with recovery or death caused by an
exciting cause or acute Miasm. The acute
miasm comes on either with sufficient
violence to cause death of the patient or with
less violence, wherein there is a period of
progress and a tendency to recover.
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While attending to an acute case, the
physician should limit his inquiry to the
recent deviation from health. Since acute
diseases require immediate medical
intervention one should not waste time in
collecting details of constitutional state and
should confine himself to the presentation of
the disease.

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1. Presenting complaints which can be described
in four components ie., location, sensation,
modlities and concomitant.
2) The feature at a general level:
a. Changes on the physical plane like
appetitie, thirst, thermal reaction,
respiration, bowel movements etc.
b. Changes on the mental plane like
irritability,confusion, fear, restlessness
etc.
The above information forms the basis of
treatment of acute diseases.

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Chronic Diseases: are those that arise from
a chronic miasm. They are insidious in
nature. In other words, they spread gradually
without being noticed. They progress
unceasingly and cause harmful effects. Their
origin cannot be traced. They make
continous inroads with or without
troublesome internal or external
expressions.

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• When left to themselves they always go on
increasing and growing and end either with
a suitable, similar remedy or with the end
of life itself.
• Chronic diseases has five phases:
Asymptomatic
Begin symptoms
Compromised function (insufficiency)
Decompensated function (failure)
End stage

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Investigation of a chronic disease must be
done in detail and should be as thorough
and searching as possible.
The details of present complaint(s), past
history, mental and physical characteristics
and family history should be taken into
account while taking a chronic case.
The majority of chronic cases are reported
after different modes of unsuccessful
treatment which most of the time, damage
the disease condition.
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Therefore, a detailed history of treatment
should be taken and its effect must be
noted down carefully in such cases.

One-sided Diseases
• One sided diseases are those chronic
diseases which present with only one or
two principal symptoms, obscuring almost
all others.

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• In a one-sided case, the case taking does
not end at one sitting but it requires detailed
inquiry at each subsequent visit.
• These successive re-examinations of the
patient and successive administrations of
the most suitable homoeopathic remedies
are to be continued till health is restored
completely.

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 CASE RECORD FORM
• OP No:
• Name: Age: Sex:
• Presenting Complaints

• H/O Presenting Complaints

• Treatment History

• Family History

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• Personal history

• Habit

• General Modality

• Generals
– Mental
– Physical

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• Eliminations

• General Examination
– H/R
– R/R
– P/R
– B/P

Systemic Examinations

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• Provisional Diagnosis

• Laboratory Investigation

• Final Diagnosis

• Management
• Rx

• Follow up

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