Case Taking:

After taking the case, tick the box to confirm that you have not missed out the following:

Acute complaints

Exactly when, why and how did it begin
Ever had this before
Did it develop gradually, or suddenly
Any changes in mood and behavior, recent stress
Thirst, appetite, bowels, urine
Sleep and dreams
Feel hot or chilly, effect of covers, uncovering
Definite modality
Signs - Face, Mouth, Sweat, Position assumed etc.
Any cravings/ aversions
What do the attendants, relatives notice that is new?

Think

What are the two most characteristic, peculiar, or prominent symptoms - Mind/ Body
What could be the underlying pathology - need to investigate/ refer?
In the past, which medicine has helped the patient most, esp in a similar situation?
Expectation - time frame for improvement, parameters
Auxiliary measures, advice to patient - diet, medication, precautions etc.


Non-Acute Complaints

Generalities

A/f...Cause, Origin
Chronicity/ Pace, progression
Family and past illnesses, never well since
Thermal state - hot/ chilly
Thirsty, Thirstless
Cravings/ Aversions   Food aggravations
Appetite, Effect of eating, fasting
Bowels - constipation, tendency to diarrhea

Mind

Who is the best source of objective information regarding this patient?
Stress, now or in past
Fears, Anger from, Sadness, Indifference
Nature - Miserly, Jealous, Suspicious, Ambitious, Revengeful, Sympathetic, Selfish
Behavior - Talkative, Hurried, Dictatorial, Impulsive, Childish, Laughing

Signs

First Impression... Anxious, Collapsed, Dirty, Confused, Impatient, Sad
Energy - robust, sickly, hyperactive, dull
Build - Obese, thin, tall, dwarfish
Complexion - blonde, brunette
Face - Frown, wrinkles, sweat, linea nasalis
Hair - fall, graying, oily
Cracks - lips, hands, heel
Color - pallor, cyanosis, blackish, red, blue
Nails - ridged, discolored, thick
Skin - warts, sweat
Teeth - caries, yellow, cupped
Tongue - coated, clean, moist, indented, mapped, furrow

Time

Morning, Forenoon, Before midnight
Periodicity, Specific time
Seasons, Weather, Sun, Seaside

Position

Sitting, Standing, Lying, Stooping
Motion < or >, continued etc.
Restlessness - limbs, involuntary movements

Discharges - menses, sweat, blood, urine

Consistency - thick, fluent, stringy
Color - dark, bright, yellow
Stains, deposits
Acridity - burning, reddening, destroys hair
Odor - offensive, fishy
Quantity - scanty, profuse
Flow - oozing, gushing, intermits

Pains, Neuralgia

Begins and Ends - slowly, suddenly
Direction - Origin, radiation, extension, localization
Nature - sharp, bursting, squeezing, burning
Concomitants - urination, jerks, sleepiness, anger, sweat
Time - specific time, during night etc.
A/f - injuries, similar in past, pathology - e.g. calculi
Modality - action taken during pain, position etc.

Think

What is the most peculiar aspect of this case?
What could be the underlying pathology - need to investigate/ refer?
What is unexplained or not understood clearly, needs further clarification?
What has helped the patient improve well in the past?
What must be asked in the follow up to assess progress?
Auxiliary measures, advice to patient - diet, medication, precautions etc.

Modality - What seems to make the cough better or worse?

Weather, climate, change of temperature   Air - draft, cold, change of room
Day, night - or specific time
Lying on back, sides, abdomen
Sleep, waking   Drinking or Eating - warm, cold, spices   Specific foods
Breathing - deep, inhaling, exhaling, holding
Expectoration >, no change
Walking, motion, exertion   Talking, reading, laughing

Signs - what can be observed

Gasping, Rattling, Sighing
Number of coughs, paroxysms, rapid bouts
Sound - ringing, barking, dry, rasping
Dry lips, mucous membranes   Face red, blue, pale   Nostrils dilated, flapping, sooty, pinched, crusty   Frown, wrinkles
Hoarseness of voice
Holds head, chest, throat, genitals

Expectoration - is the cough dry or wet? Or changeable

Profuse
Absent, dry cough
Rattling, but no expectoration
Sticky, glairy
Taste bitter, sour, salty etc
Color green, gray, yellow
Dry at one time of day or night

Location - from where does the cough seem to begin?

Throatpit   Larynx, left or right   Chest - behind sternum etc   From stomach   From a spot   Unusual - ear, spine etc.

Sensation - is there any specific sensation that provokes or accompanies the cough?

Tickling, vapor   Dryness   Lump, ball, foreign object   Suffocation, smothering   Tightness, constriction
Emptiness, hollow feeling

Concomitant - Along with the cough, are any other symptoms occurring at the same time, or before or after?

Pain in parts - head, chest, shoulder, hip
Incontinence of urine   Lachrymation   Vomiting
Fever   Sweating - face, all over
Eructations, Flatulence   Sore-throat
Nosebleed, hemorrhage   Sneezing
Discharges, postnasal, otorrhea, diarrhea, polyuria

Mind - Any change in the moods or behavior?

Moods and Temperament
Any recent Stress, fear, emotions
Effect of cough on mind
Effect of company, conversation

Generals

Onset of complaints - gradual, sudden
Thirst - sips, large amounts, absent
Hot/ Chilly/ Air-hunger
Cravings/ Aversions
Activity/ Energy/ Weakness

Diagnosis

URTI   Obstruction, foreign body, choking   Laryngitis
Bronchitis   Asthma
Bronchiectasis   Pneumonia
ILD   Tuberculosis
Heart Related
Acid reflux

Common remedies and their indications

Modality - What seems to make the diarrhea better or worse?

Passing stool - relieves, no relief
Drinking or Eating - warm, cold, spices
Weather, climate
Day, night - or specific time
Menstrual cycle, climacteric, pregnancy
Positions - lying on back, sides, abdomen
Sleep, waking
Specific foods
Emotions - anger, fear, anticipation
Walking, motion, exertion
Passing urine, coughing etc

Signs - what can be observed

Weakness, exhaustion, normal energy
Dry lips, mucous membranes, redness of anus
Open anus, incontinence of stool or urine
Gurgling, borborygmi
Sweating, coldness

Nature of stool - color, consistency, odor, frequency, quantity

Profuse, large quantities, scanty stool, only mucus
frequent, at long intervals
Odorless, offensive, sour, penetrating
Color of stool - green, yellow, white, brown, reddish etc
Consistency - frothy, curdy, watery, jelly-like, mucus, blood

Sensation - is there any specific sensation in the abdomen, anus etc

Painful stool or painless/ Abdominal colic/ Tenesmus
Emptiness, hollowness
Sense of insecurity
Swashing in stomach or abdomen
Nausea
Distension, fullness

Concomitant - Along with the diarrhea, are any other symptoms occurring at the same time, or before or after?

Pains anywhere in body, cramps
Incontinence of urine
Vomiting
Fever
Sweating - face, all over
Eructations, Flatulence
Piles
Fainting
Discharges, postnasal, otorrhea, diarrhea, polyuria

Mind - Any change in the moods or behavior?

Moods and Temperament
Any recent Stress, fear, emotions
Effect of the diarrhea on mind - anxious, dull
Effect of company, conversation

Generals

Thirst - sips, large amounts, absent
Hot/ Chilly
Cravings/ Aversions
Activity/ Energy/ Weakness

Diagnosis

Infectious - bacterial, parasitic
Inflammatory bowel disease
Irritable bowel syndrome
Dysentery
Nervous, emotional
Food intolerance - lactose, gluten

Common remedies and their indications

What was the first hint or sign of the illness?
Describe the onset of the fever - starting from the day before
What could be the possible cause?
Any recent emotional stress, shock?
Any physical exertion, injury or exposure


Feeling mainly hot or chilly?
Is there a sequence - chill, fever etc
How does the fever come and go, or is it constant?
What is the maximum and minimum temperature in a day?
Any periodicity - specific time of onset? When is it most?
Effect of covers, external warmth
How much sweat?
Where is the sweat - on single parts or all over?
Does the sweat occur at specific times, or under certain conditions - eg, when sleeping?
Where from does the chill or heat begin initially? Which parts is it prominent?
Are some parts of the body hotter or colder than others?


What gives the most relief? Some position, time, doing something?
What causes complaints to increase or worsen?
Any specific symptoms or complaints before, during or after fever?


Effect of eating, drinking?
How is the thirst? More, less, absent, sips - only during heat/chill
How is the Appetite and taste in the mouth?
Any specific food cravings or aversions that have developed?


How is the mood, behavior? Any change from usual?
How is the reaction to company, conversation?
Is the patient silent, talkative, cooperative, manner of replying?
Any confusion, delirium, loss of consciousness?
Any anxiety, restlessness, sadness, indifference, irritability?


What is the appearance like? Congested, alert, weak, cachectic...
What signs are visible - dryness, frown, tongue, eyes, jaundice, cold extremities, sweat, trembling?


What symptoms have been most persistent since onset of complaint?
What symptoms have been most prominent since onset of complaint?


What could be the diagnosis - malaria, 'flu, typhoid, pus somewhere...
What investigations are required?
What advise beside medication? ...sponging, plenty of fluids, don't swaddle etc.


Common remedies and their indications

Location - where is the pain or discomfort

one side, left, right, one spot, occiput, vertex...
ascending, backward, forward, descending
changing sides, alternating
root of nose, protuberances, in a line, ear to ear
extending to ear, nose, upward, other parts

Sensation - what is the main sensation

bursting, throbbing, pulsating
like a string, drawing in
expansion, enlarged
hammering, beating
heavy, like a load
swashing, moving, shaking, waving
constriction, band, compressed, pressing
burning, hot, cold, frozen
numbness, wooden
sore, sensitive
emptiness, hollow

Causation and modality - What causes and aggravates or relieves?

time - periodic, day, night, afternoon
food - eating, drinking, fasting, overeating, specific foods
covers, uncovering, heat, cold
exposure to sun
motion, walking, jar, coughing
touch, pressure, binding hair, bandage
lying - side, back, propped up
seasons - summer, winter, rainy, autumn
exertion - mental, physical, eye-strain, studying
sleep - loss of, excess, afternoon
injury
light, noise
discharges - vomiting, stool, sweat, menses
before, during or after menses
emotions, stress, worry

Signs - what can be observed?

congestion of face, head, eyes, lips
pallor, bluish
eyes - lachrymation, staring, drooping lids, photophobia
frown, wrinkled forehead
jerks of head, movements
salivation, dryness of mouth
covers, binds head, wants air
discharges - sweat, coryza, vomiting, otorrhea
position - leaning head, lying
holds head

Concomitant - what complaints accompany the headache?

coryza, cough, fever
nausea, retching, vomiting
acidity, eructations
constipation, diarrhea
neck stiffness, weakness, pain
weakness
sweating
increased or decreased thirst
earache, ear problems, tinnitus
increased appetite, thirst
confusion, dullness, irritability

Mind - Any change in the moods or behavior?

Moods and Temperament
Any recent Stress, fear, emotions
Effect of headache on mind
Effect of company, conversation

Generals

Sleep, effect of sleep
Thirst - sips, large amounts, absent
Hot/ Chilly
Cravings/ Aversions
Activity/ Energy/ Weakness

Diagnosis

Sinusitis
Hypertension
Tension headache
Migraine
Eye strain or eye complaints
CNS - meningitis, SOL, concussion
Hangover, alcohol induced
Food allergy
PMS

Common remedies and their indications

Location - where is the pain or discomfort

left-side, right-side, in one spot, all over
ascending or descending complaints
changing sides, alternating
tonsils, adenoids, soft palate
extending to ear, nose, upward, other parts

Sensation - what is the main sensation

rawness, soreness
burning, heat
sharp, splinter or fish-bone
constriction, choking, spasm, stiff
itching
as if a hair or thread
something stuck, crumbs, hanging loose
lump, ball, plug
dryness, roughness
throbbing

Causation - What might be the possible cause?

exposure, getting chilled or overheated
cold drinks, ice creams
over-exertion of voice
physical exertion
eating sweets

Modality - What seems to make the throat complaint better or worse?

swallowing - empty, food, water
talking - loudly, reading
warm or cold food or water, ice creams
inspiration, breathing
expectoration
covers, external warmth or cold
putting tongue out
touch or pressure on external throat

Signs - what can be observed?

inflamed or enlarged tonsils
color - bright or dark red, bluish, white
pus, deposits, membrane
swelling, edema, uvula swollen
offensive breath salivation, dryness of mouth tongue protruded, difficult to put out cracked lips, corners difficulty in swallowing holds throat, covers up etc voice altered, hoarse enlarged lymph nodes, glands

Concomitant - what complaints accompany the sore-throat?

coryza, cough, fever
chills
swallowing - difficulty or frequent attempts
dullness
gagging, nausea
weakness
sweating
increased or decreased thirst
earache, ear problems, deafness
acidity, heartburn, reflux

Mind - Any change in the moods or behavior?

Moods and Temperament
Any recent Stress, fear, emotions
Effect of sore-throat on mind
Effect of company, conversation

Generals

Sleep, effect of sleep
Thirst - sips, large amounts, absent
Hot/ Chilly
Cravings/ Aversions
Activity/ Energy/ Weakness

Diagnosis

Tonsilitis
Acid-reflux
Pharyngitis

Common remedies and their indications

Modality - What seems to make the Vertigo better or worse?

Position - sitting, standing, lying on side or back, bending head
Movement - of eyes, body, limbs, being still, rising, continued/ fast/ slow
Eating, hunger, specific meals - breakfast etc
smoking, alcohol, coffee, drugs, medication
Day, night - or specific time
Environment - summer, hot room, open air, high altitude
Sleep, waking, falling asleep
Emotions - fear, anticipation, shock, grief
Pregnancy, menses
Motion sickness, car, bus, train etc
Loss of fluids, diarrhea, passing stool or urine
vomiting

Signs - what can be observed

Pallor, pale lips, white face
Sweaty, sweat on face, head, body
Eyes closed, open
Position - sitting, lying, lying on side or semi-erect
Movements of eyes, nystagmus, dilated pupils
Salivation, increased discharges
Emotions - fear, confusion, sadness, anxiety, irritability
Flushing

Sensation - what is the main sensation

Objects or room seems to move, spin
Feels being pushed or thrown
As if missing a step, falling down
As if floating, not touching bed or floor
Weakness, energy draining away
Nausea, qualmish
Cannot focus, blurred, darkness
Hot or cold waves, flushes
Some image, illusion in front of eyes

Concomitant - Along with the vertigo, are any other symptoms occurring at the same time, or before or after?

Nausea or vomiting
Tinnitus, sounds in ears
Visual disturbances
Palpitation, heart complaint
Salivation
Weakness, sinking, fainting
Trembling, twitching
Sweating - face, all over
Otorrhea, diarrhea, frequent urination, nosebleed
Pain anywhere - earache, renal colic

Mind - Any change in the moods or behavior?

Moods and Temperament
Any recent Stress, fear, emotions
Effect of vertigo on mind
Effect of company, conversation

Generals

Sleep, effect of sleep
Thirst - sips, large amounts, absent
Hot/ Chilly
Cravings/ Aversions
Activity/ Energy/ Weakness

Diagnosis

Emotions, Nervous
Ear infection or disease, BPPV
Neck - spondylosis
Heart disease
Motion-sickness
Drugs, medication, change of meds, overdose
Brain or nervous system
Orthostatic hypotension
Loss of fluids - vomiting, bleeding, sweating
Nutritional - fasting, deficiency, anemia

Common remedies and their indications

Modality - What seems to make the Nausea/Vomiting better or worse?

Vomiting amel, does not relieve
Drinking or Eating - immediately, after some time, warm or cold food and drink
Weather, climate
Day, night - or specific time
Positions - lying on back, sides, abdomen
Sleep, waking
Specific foods - eggs, fish, fatty food, seafood, icecream
Emotions - fear, anticipation
Pregnancy, menses
Motion sickness, walking, motion, exertion, altitude
Passing stool or urine, coughing etc.

Signs - what can be observed

Dry lips, mucous membranes
Tongue coated, moist, dry
Weakness, exhaustion, normal energy
Sleepiness, dullness, confusion

Nature of Vomitus - color, consistency, odor, frequency, quantity

Profuse, large quantities, only retching
Frequent, at long intervals
Undigested food, food eaten long back, only liquids
Offensiveness, no odor, sourness
Color - green, yellow, white, brown, reddish etc
Consistency - frothy, curdy, watery, milky, mucus, glairy, blood

Sensation - is there any burning, pain, griping, coldness

abdominal colic, pain in a spot or region
constriction
sharp pains, cutting, stabbing
cramps, twisting, griping
burning, acidic
coldness
water, swashing, sloshing or flopping in
fullness, distension

Concomitant - Along with the vomiting, are any other symptoms occurring at the same time, or before or after?

headache
appetite poor, ravenous
thirsty, thirstless
with nausea, without nausea
salivation
eructations, belching
fever
sweating - face, all over
diarrhea
trembling
vertigo

Mind - Any change in the moods or behavior?

Moods and Temperament
Any recent Stress, fear, emotions
Effect of vomiting on mind
Effect of company, conversation

Generals

Thirst - sips, large amounts, absent
Hot/ Chilly
Cravings/ Aversions
Activity/ Energy/ Weakness

Diagnosis

Gastroenteritis
Acidity
Emotions, Nervous
Obstruction
Renal failure
Brain or nervous system
Liver disease, jaundice
Caused by pain

Common remedies and their indications