How to take the Case History
Students of homoeopathy often don't know where to begin, and how to proceed with a case taking. I was asked by some students recently, and decided to put down some guidelines.
- The first thing required is an open mind, free of prejudice. Don't jump to conclusions based on the patient's accent or appearance; or get upset if children are making noise, pulling things etc. Sometimes patients come in a crowd, and they all want to say something, or one person (not the patient), might want to speak more and show some authority. Some people throw names - I know so and so etc., which should neither impress you or irritate you. All these things are common. Some patients might be very rich, others very poor. These are not what we should focus on. What we need to remember is that they are coming with a complaint, asking for our help. Our interest is in getting the history as completely and accurately as possible. We should learn to manage their behaviour so that we can proceed with our work properly. Politely ask some people to wait outside, or listen for a few minutes to an agitated relative - and then tell them how you want to take the case.
- Allocate enough time for a new case, so that you don't have to rush through. If they don't have time, tell them to come back again on another day. For an acute case, you may need 20 minutes, and for a chronic case, about 45 minutes or rarely, even 1.5 hours. However, a very long case taking is almost always counter-productive and mostly shows that you have no clue about what you are doing.
- All phones must be switched off, and there should be no disturbances or interruptions. If it is a retake of a patient who has not improved with your previous prescriptions, ideally call them on a day when there are no patients - even a Sunday if needed - serious cases where you want to do your best work.
- You should be in a very receptive mood, not thinking of other things - thinking of how you need to leave for some party or meeting etc. as soon as the case is over. If you need to, eat a quick snack before you begin taking the case. The right frame of mind to take a case well is: calm, patient, empathetic, curious and observant. You should be genuinely interested in what is happening to the patient, his story, understand what he means, follow the thread clearly. All unusual details must be noted and followed through.
- Begin by asking the patient to tell you his or her complaints. Use a few A4 sheets of paper to note down the history. As far as possible, try not to interrupt. If they jump from one complaint to another, write one complaint, leave some space and below, write the other complaint. Let them go with their own flow. For example, you can write 1. cough since 3 months, worse in the past 3 days... and below after leaving some space, 2. severe headache in right side of head since this morning. Later, when they add some information about the cough, you can add it to the appropriate section. You can also ask for the modalities and so on, and complete it. The idea is to let them speak freely without trying to get information as per your interests or train of thought.
- Once the patient has finished telling you all that he or she wants to say, you can ask "what else?". This may start them speaking again. Do this till they are done giving all the information they can spontaneously give. If a patient is very taciturn and gives hardly any complaints, you can start asking questions to get specific information.
- Early in the case-taking, it may be useful to say - I know you're coming for the joint pains, but in homoeopathy we need information about all your other complaints, including any worries or tensions, so please give a complete history, even if you feel it is unrelated to your joint problem. That way I will be able to help you much better.
- Once you have the chief complaint and other associated complaints, try and complete them with reference to: Location, Sensation, Modality and Concomitants. So you should know what might have caused the complaint, what makes it better or worse, including any specific time, position etc. Then, what are the accompanying complaints - such as nausea or dizziness with the headache. For a new student, going through the "case-taking" checklist will be very useful.
- All those questions should be read, re-read and memorized. Then you will not struggle to think of what to ask next. A good knowledge of keynotes of the Materia Medica will also guide us as to what kind of information we need in order to prescribe. Thus, in a headache, knowing whether it is worse from exposure to the sun, or hunger, or sleep - or if the pain goes up from the occiput to the top of the head etc. - this is very basic and vital. If we know our keynotes, we will know that such information can quickly point us to some remedies. Whenever you read keynotes, think - "how would i ask a patient for this information?". So if you see in Lachesis, left to right - the question would be - "where did the complaint first begin, and has it spread in any way?" etc.
- At the end of the case taking, go through the case-taking checklist on this site, and see if you have got all the information. If something was not asked, ask now and get the remaining history. Ensure that you get the history from the patient as well as someone who knows the patient well - and is talkative! Then you will have a good history. If the patient has been referred by a doctor, call the doctor and get more information. If the patient has improved well with the prescription of some other doctor, make a careful note of it in your history. Underline all the important information - especially what is very prominent, persistent or peculiar. When you look at your history a week later, you should be able to immediately see at a glance what was most important in the case.
- After you analyse the case and make your first prescription, write down the reasons for the selection of remedy. Also any other remedy you had in mind, and lastly, the things that did not make sense or which did not fit into your analysis. Then, if the patient does not improve, you can look at this and see if something else is indicated.
- During the case-taking, focus first on the information you need for a homoeopathic prescription, but before you prescribe, be sure to think of the clinical diagnosis and what things might help the patient in addition to your remedy. For example, steam inhalation or saline nasal drops in a sinusitis. Or telling a patient to use a mosquito net or repellents etc.