Patient Statement Case Recording

How to make a patient statement accurately

Transcript

1. Dr. Kazi Shaif Uddin Ahmed B.Sc. (Bio-Chemistry) DU, DHMS (Board stand)BHB, Pg hom (UK) Lecture Federal Homoeopathic Medical College and Hospital, Dhaka, Bangladesh
3. Durood-E-Ibrahim
4. Dua for Success
8. Subject Today: Practical Process of Homoeopathic Case Taking
9. Definition: Case taking is the Practical process of collecting all the facts about the patient, using various tools like observation, perception, history-taking – given by the patient , attendant, clinical examination etc.
10. In order to find a remedy for the patient – using our knowledge of Homeopathic Organon of Medicine, Materia Medica, Chronic Diseases, and Reparatory. find a remedy Written in: 1833 Published in : 1921 $153,Footnote 109 $143 - $ 145 $205 using our knowledge………… Lm / 50 Millesimal Potency
11. Objective of Case-Taking: Collection of all the facts pertaining to the patient, which may help in reaching to the totality of the patient and thereby help in finding the correct similimum. It is also said that a case well taken is a case half cured. AIM OF correct similimum
12. To find out mirror image of symptom totality.
13. Dr. Hannemann said that Aphorism $148 , Footnote 108– Sixth Edition of “Organon of Medicine” But this laborious, sometimes very laborious, search for and selection of the homoeopathic remedy most suitable in every respect to each morbid state (Diseases)……………………….. How could his laborious, care-demanding task, by which alone the best way of curing diseases is rendered possible………….
14. Dr. Hannemann said that Aphorism § 149 Sixth Edition of “Organon of Medicine” Diseases of long standing (and especially such as are of a complicated character) require for their cure a proportionately longer time. ……………..
15. Dr. Samuel Hahnemenn’s guidelines regarding the art of case-taking Dr. Hahnemann in his ‘Organon of Medicine’, aphorisms $5, $6, 83-104, and footnote 108, $208 $209 has given the following instructions regarding the method of case-taking:
16. Discussion of Practical Process of “Patient Statement Or Case Recording”
17. Two Part of Practical Process of “Patient Statement Or Case Recording” 1st part : 2nd part : Art of Case Taking Write down “Case Taking Form”
20. HOMOEOPATHIC
21. Patient Statement Or Case Recording ( Only For Physician - Secret )
22. Patient ID No: Visit Date:
23. Patient Name : Pls, write down full name of Patient. [Complete ] [Generalities]Food and drinks: Beef:Desires: [Murphy ] [Food]Pork, general: Desires:
24. Religion : Muslim / Hindu / Christian / Buddhist [Kent ] [Genitalia male]Phimosis:Paraphimosis: Total Drugs : 11 3 Merc Mercurius Solubilis Hahnemanni 3 Nit-ac Nitricum Acidum 2 Coloc Citrullus Colocynthis 2 Lach Lachesis Mutus 2 Merc-c Mercurius Corrosivus [Complete ] [Male Genitalia]Operation for circumcision, after: Total Drugs : 1 Staph Staphysagria Paraphimosis Phimosis no reference to male circumcision in the Hindu holy books, and both Hinduism and Buddhism appear to have a neutral ... ………
25. Age: ………years. The Twelve Stages of the Human Life Cycle [Complete ] [Rectum] Hemorrhage: in old women: Total Drugs : 2 Drug Mark Remedy Name Remedy Full Name 4 NAT-M Natrum Muriaticum 3 Psor Psorinum [Complete ] [Rectum] Hemorrhage:I nfants, in: Total Drugs : 1 Drug Mark Remedy Name Remedy Full Name 1 All-c Allium Cepa
27. Name of Father / Husband / Guardian name: [Kent ] [Mind]Mildness: [Complete ] [Mind] Anger: Violent: [Murphy ] [Mind] MELANCHOLY, mood, (see Depression, Gloomy):
28. Sex: Male/ Female / Child [Kent ] [Generalities]Emaciation: Pining boys: Total Drugs : 4 [Kent ] [Head] Pain, headache in general: School girls: Total Drugs : 8 [Complete ] [Eyes]Cataract, opacity of lens: Women, in: Total Drugs : 1 [Boenning ] [Sensation and complaints in general] Infants: Constipation :Total Drugs : 7 [Kent ] [Prostate gland] Emission prostatic fluid: Urination: After: Total Drugs : 15 Nux-vomica Aethusa cynapium PULSATILLA NIGRICANS
29. Date of Birth : … ……..In Astrohomoeopathy, which is a “Astrology and Homoeopathy” beautiful blend of Astrology and Homoeopathy, the horoscope serves as an invaluable diagnostic tool to provide a unique insight into the patient’s mental, emotional and physical makeup, which is indicated by the placement of planets in various signs and houses at the time of birth.
30. Blood Group :
31. Handed: Right / Left
32. Address: Slum Area Diplomatic area Village area Dry to wet area
33. Contact no. Office / Res / Mobile:-
34. Profession (Nature of Work) : [Complete ] [Mind]Deceitful, sly:Corrupt, venal: Politicians: Total Drugs : 15 [Kent ] [Head]Pain,headache in general: School girls: Total Drugs : 8
35. Education : No of Brother & Sister: Brother : Sister : Position of patient: Death : At what age & how dead :
36. Single / Married (Love / arrange )/ Divorced / Widow / Widower/ 2nd Married [Knerr ] [Female Sexual Organs]Sexual excitement (desire):Increased desire: Divorced woman, in a: Total Drugs : 1 [Complete ] [Female Genitalia]Sexual, libido:Desire:Violent:Widows, in: Total Drugs : 7 [Kent ] [Bladder]Urination:Dysuria: Married women,newly: Total Drugs : 3 [Clarke ] [Temperaments]Women:Old:Unmarried: Total Drugs : 3 Love time : Date of married : After how long being widowed again married: How many day being away from husband/wife : Children : Yes / No / Late / Sterile Number of Child : Boy Girl Cause: Death:
37. Constitutional Structure: Hight : Tall / Medium / Short [Khullar ] [Tuberculosis]CONSTITUTION: Tall, lean, slender:Fair complexion, consumptive: Total Drugs : 2 [Kent ] [Genitalia female]Menses:Copious: Tall women: Total Drugs : 1
38. Build : Emaciation/ Dwarfish / lean / Scrawny / Normal / Obesity [Kent ] [Generalities] Emaciation: Total Drugs : 116 [Murphy ] [Generals] OBESITY, general:Children, in: T otal Drugs : 10 [Kent ] [Generalities]Dwarfishness: Total Drugs : 14 [Kent ] [Generalities]Obesity: Total Drugs : 50 [Murphy ] [Constitutions] LEAN, thin constitutions: Scrawny: T otal Drugs : 1
39. Complexion : Fair, Blond, Light / Dark, Brunette [Complete ] [Generalities]Complexion, color of eyes, face, hair:Dark, brunette:T otal Drugs : 96 [Murphy ] [Generals]Complexions, general, (see Hair, general):Fair, blonde, light: Total Drugs : 45 Face: [Kent ] [Face]Chlorotic: Total Drugs : 50 [Kent ] [Face]Cracked: Lips: Lower lip: Total Drugs : 7 Lip: Teeth : Hair: [Kent ] [Teeth]Caries,decayed,hollow: Premature in children: Total Drugs : 7
40. Miasm : Psora / Sycosis / Syphilis / Tubercular / Cancer [Murphy ] [Clinical]PSORA, miasm: Total Drugs : 218 [Murphy ] [Clinical]Sycosis, miasm: Total Drugs : 184 [Murphy ] [Clinical]Syphilis, miasm: [Murphy ] [Cancer]Miasm, cancer: Total Drugs : 28 Total Drugs : 183 [Murphy ] [Clinical]Tuberculosis, miasm: Total Drugs : 115
41. Hereditary Disease or Family History: Relationship P G. F. P.G. M M.G. F. M. G. M. Father Mother Brother Sister Paternal Uncle / Aunts Maternal Uncle / Aunts Alive / Dead Age Diseases suffered Cause of Death
42. Is there any sort of disease of the mother during the period of her pregnancy: Past medical History, Drug History, Family History, Social History , Systematic enquiry Birth History :
43. Vaccination & Inoculations :
44. [Complete ] [Generalities] Vaccination:After, ailments from: Total Drugs : 100 (total remedy of complete repertory 1725)
46. History of Trauma: Broken bones / Accidents /Head injuries /Surgery / Caesarean operation / Colonoscopy / Rectal scope / Endoscopy / TVS / DNC/ MR etc. [Kent]][Clinical]Organs, [Generalities]Injuries [Murphy injury,(including to internal:blows,falls bruises): Total Drugs : 49 Totaland Drugs :3 3 Bell-p Bellis Perennis [Murphy ] [Generals]Pain, 2 Mill Achillea Millefolium general: Surgery, pain after: Total Drugs :5 1 Arn Arnica Montana
47. Bite : Dog / Cat / Snake / Fox / Bee / Scorpion / Rat / Insect etc. [Complete ] [Generalities] Wounds: Bites: Dogs, of: Total Drugs : 49 [Murphy ] [Clinical]Bites, general, animals and insects, from: Total Drugs : 24
48. Past Medical History & Drug used : Name of Appro Duration Diseases & ximat suffered from e Age Whether You Completely recovered Medicines & Any treatment taken other (Allopathic / particular herbal / s Homoeopathy Childhood Age 1 to 18 Adulthood Age 19 upto [Complete ] [Skin] Itching: Jaundice: After: Total Drugs : 1 [Complete ] [Eyes]Cataract, opacity of lens: Fever, after typhoid: Total Drugs : 1
49. Mental Investigation Present Symptoms / Chief Complaints: Duration:,Time:,Causation:,Location &Extension: ,Sensation: ,Nature of Characters: Side: ,Amelioration:,Aggravation:,Concomitants: Regional or Particulars:a) Head to Neck : 1) Vertigo 2) Head 3) Eye 4) Vision 5) Ear 6) Hearing 7) Nose, Smell 8) Face 9) Mouth, Tongue, Taste 10) Teeth 11) Throat 12) External Throat a) G. I. Track (Elementary System):- 1) Stomach 2) Abdomen 3) Rectum 4) Stool Mental truma : Despair / Grief, Grief silent / Disappointed love / Unhappy /Sadness /Anguish / Forsaken/ insult / Temperament : Melancholic / Phlegmatic / Nervous / Choleric / Sanguine Diathesis :Hemorrhagic / Scrofulous / Nervous / Forgetfulness / absent-minded / Avarice or greedy/ Irritability /Anger / Rage / Cruelty / Obstinate /Contradiction / Anxiety / Confusion / Concentration / Cheerful / Dullness / Delirium / Deceitful / Egotism/ Insanity / Loquacity / Jealousy / Mental Depression / Mood , changeable / Restlessness / Sensitive / Suspicious / Timidity / Hyperactivity / Dwarfishness / Foolish / Memory power: Active / Weakness Fear , Anxiety: alone/ animals (Chicken ,Cat, dog, snake, )/ Accidents/ approaching him/ Blood/ Crowd/ Dark/ Death/ disease Doctor/ (Cancer, )/ Evil/ Future about/ Earthquakes/ Ghost/ Germs/ Insanity/ Insect (germs, bugs, Cockroaches)/ Noise/ Narrow place/ Misfortune/ poverty/ people/ Robber/ Suffering/ Suffocation/ Street/ Thunderstorm, Weeping: Easily / Whimpering / Lamenting / Complaining Tearful mood / sleep, in / Dream : Accidents / Amorous / Animals / Anxious / Danger / Dead / Death/ Falling of / Fire / Frightful / Journey / Lascivious /Misfortune of / Murder /Nightmare / Pleasant / Unpleasant / Religious / Quarrels / Sad / Vivid/ Water Sleep: Deep / Short / Disturbed / Insomnia / Sleeplessness / Yawning c) Uro-genital System:1) Bladder 2) Kidneys 3) Prostrate gland 4) Urethra 5) Urine& Urination 6) Male Genitalia 7) Female Genitalia d) Respiratory System :- 1) Larynx & Trachea 2) Respiration 3) Cough 4) Expectoration 5) Chest d) Back & Extremities:- e) Skins:- Warts / Corn / Spot Mistake: Position: Side :Left / Right: Sweat / Perspiration: Trouble: Weather / Season Change:
50. APPETITE& THIRST : Appetite / Hunger : Increased / Ravenous, excessive / Wanting / Easy satiety / Diminished Warm food / Drink or Cold food / Drink : Desire / Aversion Thirst / Thirstlessness Foods Desire / Like Aversion / Disagrees Dislike Foods Agg KENT, STOMACH , Aversion p. 480 Kent, Stomach, aversion, bread (p. 480) kent, Stomach, aversion, coffee (p. 480) Stomach, aversion, food, hunger, with (p. 481) KENT, STOMACH , Desire p. 483 KENT, Stomach, desires, bitter, food (p. 484) KENT, Stomach, desires, cold drinks (p. 484) KENT, Stomach, desires, farinaceous food (p. 485) Food Amel Foods Desire / Likes Aversion / Dislike Disagre es Foods Agg Food Amel KENT, GENERALITIES FOOD Agg/amel, p. 1362 Generalities, food, bread agg. (p. 1362) Generalities, food, bread, black, agg. (p. 1362) Generalities, food, bread, butter, and, agg. (p. 1362)
51. Data of personal Habits: [Kent ] [Mind]Work:Aversion to mental: Total Drugs : 107 [Kent ] [Mind] Indolence, aversion to work: Total Drugs : 138 [Kent ] [Mind]Travel,desire to: Total Drugs : 12
52. Data of Family Life Space:
53. Sexual Life System : [Complete ] [Mind]Husband:Aversion to: Total Drugs : 25 [Kent ] [Mind]Forsaken feeling: Total Drugs : 32 [Kent ] [Genitalia male]Coition: Aversion to: Total Drugs : 17 For Man only :Erection : Difficulty / wanted / unwanted / Weak / Failing /premature Ejaculation [Murphy ] [Male]Ejaculation, general, (see Seminal, Emissions):Premature, too quick, (see Impotency): Total Drugs : 45
54. For Women’s only: Menstruation: Kent –P-724 Started age (FMP) LMP Cycle Time Duration Quantity Profuse / Scanty Smell Hot & Cold Offensive Color Bright, red / Black / Pale Suffer KENT, GENITALIA FEMALE , p. 724 Genitalia female, menses, clotted (p. 725) Genitalia female, menses, copious (p. 725) Genitalia female, menses, copious, daytime (p. 725) Genitalia female, menses, dark (p. 726) Genitalia female, menses, delayed in girls, first menses (p. 726) [Kent ] [Genitalia female] Menses: Clotted: Total Drugs : 75 Flow Stains Regular / Irregular / Suppressed Thick / Thin, watery / clotted
55. Leucorrhoea :Kent- P-720 Started age Periods Time Duration Quantity Smell Color Flow Hot & Cold Suffer Stains KENT, GENITALIA FEMALE p. 720 Genitalia female, leucorrhœa, acrid, excoriating (p. 721) Genitalia female, leucorrhœa, albuminous (p. 721) Genitalia female, leucorrhœa, bland (p. 721) Genitalia female, leucorrhœa, copious (p. 721) Genitalia female, leucorrhœa, greenish (p. 722) Genitalia female, leucorrhœa, menses, before (p. 722) [Kent ] [Genitalia female] Leucorrhoea: Total Drugs : 143
56. Pathological Investigations: Diagnosis: First Prescription : Follow Ups Date Complaints Name of the Medicine & Dose
57. References: 1. Organon of medicine by Samuel Hahnemann – B.K.Sarkar 2. Essentials of repetorisation- S.K.Tiwari 3. Kents lectures on Homoeopathic philosophy 4. Genius of Homoeopathy- Stuartclose 5. Principles and art of cure in Homoeopathy- H.A.Robert 6. A brief study course on Homoeopathy- Elizabeth Wright. 7. Logic of Repertories- Castro 8. Writings on Homoeopathy- Kanjilal 9. Hutchison’s Clinical Methods 10.The art of case taking- Pierrie Schmidt 11.The art of interrogation – Pierrie Schmidt 12.An introduction to Principles of repertory and repertorization- Muneer Ahmed 13.Spirit of Homoeopathy-Rajan Sankaran 14.Science of Homoeopathy- George Widhulkas 15.Principles and practice of Homoeopathy- Dhawale 16.Significance of past history in Homoeopathic prescribing-Foubister 17.Manual of Psychiatry- J.P.S. Bakshi 18.Dr.K.B.Rameshan -Principal in charge and professor in Department of Case taking and repertorisation, GHMC Calicut. 19. 20.Text Book of Repertory- Niranjan Mohanthy 21.Case Taking, Case receiving and recording – Niranjan Mohanthy. 22.Art of case taking and practical repertorisation- R.P.Patel 23.’Case taking a developmental approach’ – Seminar paper presented by Mansoor Ali
59. END