The Case In Totality
NATIONAL JOURNAL OF HOMOEOPATHY 1996 Nov / Dec Vol V No 6.
Vishpala Parthasarathy.
Cases.
` Bry / Lach / Tub / Rhus-t / Nux-v / Sil / Phos

Introduction

This paper was read at NJH Aurangabad Seminar on 30 June 1996. Though the vitality and vivacity of the slides and live speech cannot be entirely translated on paper, yet the entire paper is given herewith, to benefit those who did not attend the Seminar.

HEALTH = EQUILIBRIUM = BALANCE.
DISEASE = DISEQUILIBRIUM = IMBALANCE.
TREATMENT = RIGHTING THE IMBALANCE
CASE TAKING IS A STUDY OF:-.

1. Development of the patient from early childhood to date.
2. Background - social and cultural.
3. Past history & Family history which give us the Miasmatic background.

Effective case taking helps in two ways :

1. It is the foundation on which diagnosis, prognosis and treatment of the patient is decided.
2. The rapport built between patient and doctor allows emotional catharsis which in itself is healing.

The Diagnosis of disease helps know the course of the disease and prognosis and also helps in selecting the potency and repetition.

The Diagnosis of the patient will tell us:.

1. What kind of a person is he?.
2. What has happened?.
3. And most importantly, what life has meted out to him? And.
4. Why has he fallen ill?.

In case taking just listening to the patient is not enough. In addition to the Examination, OBSERVATION of the patient is of paramount importance. To a physician, more so to the Homoeopath, close observation can provide valuable clues leading to the remedy. Observation should not be too blatant so as to make the patient conscious. That will undo the benefits of observation.

While taking history, look for clues in - Demeanour, discomfort, anxiety (Ars) fidgetiness, tense, suspicious, dull, hyperactive, quivering lips, (Puls) blank look, cleanliness, manner of dressing, lie, braging (Plat) faith or lack of it, shifty eyes Taren, tendency to touch. (Phos) Dictatorial (Lyco) so on.

The types of Case Record:.

1. Open, blank paper approach.
2. Formatted type.

I use SCR (Standardized Case Record) developed by late Dr. M L Dhawale.

The SCR is divided into "3" PARTS.

1. Chief complaints.
2. Associated complaints.
   Both are to be categorised as.
   Location, Sensation, Modalities and Concomitants.
3. Patient as a person.
   1. Physical - Head to toe including skin, menses, height, weight etc.
   2. Emotional including Life story, sleep, dreams.
   3. Reaction to factors-physical - Mental Including modalities, Chronology etc.
   4. Examination - General & systemic.
   5. Past history.
   6. Family history.
   7. Investigation earn to scan the reports sometimes patient comes.

Some physicians prefer the open format so that history is written without interruption. But the formatted case record also is to be entered as the patient talks. Physician is familiar enough with his own case book, and can jump to relevant reaction as patient talks. It is not meant to be used as a questionnaire to fill up item wise. But latter he can fill in missing section; for example cravings (so go to appetite and so on). This approach has many advantages over open approach paper.

1. No data is missed out.
2. Follow-up is much easier, since it is itemized and can be located in seconds.
3. Connected data can be entered in the same places, for example: He gives a family history of Father a diabetic; then after 10 minutes says Mother has asthma. All can be entered on the same page since space is allocated already.
4. Different doctors can follow up a patient without missing points. For example your assistant can follow up the case without missing points of follow-up.
5. All this is specially important in a Homoeopathic patient, where a patient comes for treatment for long period of time and it is necessary to keep track of all his complaints, before pronouncing him cured.
6. For new practitioners too, the formatted case book ensures nothing is missed out in a case. They have an advantage; they can improvise the format they are using with their knowledge.
7. The main argument against a case book is that the record is not in patients own words and that patient is not allowed to talk but is interrupted. There is a page of chronological sequence where the history as told can be recorded. Also the patient is allowed to talk without interruption, recording is carried on in the appropriate section by the doctor. Therefore, both arguments are not valid and can be circumvented even in a formatted case book for optimum results.
8. Each patient has an individual book, filed according to the surname. So all case books of a family, say Mehta, are filed together under M.

Even years later if the patient comes again the case book can be retrieved in a fi.

A SYSTEMATIC APPROACH always gains over a non-systematized one. this is true for all facets of life.

With this we complete CASE TAKING.

So, remember the important points.

1. Importance of format.
2. Making of a format.
3. Listen well and jot down in your format in the relevant page as the patient talks, without interruption.
4. Later only ask relevant or leading Questions, as the case may be, incomplete.
5. Relevant clinical examination to confirm clinical diagnosis.

How to work out a case:? i.e. the Analysis.

Repeated use of case book helps to train the mind into proper case taking and analysis. Remember, when we begin practice, we do not have the knowledge of all remedies of the Materia Medica and yet we should be able to work out a case and come to a small group of remedies which is then possible to refer to in the materia medica and conclude.

Conceptual image (The 20 pt programme).

PS SYC TUB SYPH

1. Cause
2. Aggr
3. Amel
4. Phy Generals
5. Characteristic.

Particulars

1. SYNTHESIS : Structuralization : All the data collection including the evolution of the patient, is to be organised in a grid pattern. This we call the structure of the case. Where every data we have about the patient to form a flow chart. From this we can clearly understand how the patient has evolved.
2. ESSENTIAL TOTALITY : This is the core of the case, or the most important symptoms, from which the Repertorial totality can be made.
   Miasmatic cleavage : To decide about predominant Miasm from Past family history and select anti-Miasmatic remedy which will help to complete the cure.
3. Repertorial totality : Above Essential totality to be translated into repertory language worked out and come to a group of remedies.
4. Differentiation of remedy based on Materia Medica. Now we will demonstrate application of the above theory in a few cases:.

Case 1:

54 years female, came in 1985 with her face full of warts 100 at least. It was a challenge for me as already taken "H" from a senior.

Mrs. PA Age : 54 Married : 1954 (31) Religion : Sikh.
Diet : Non-veg Spouse : Business, owns 2-3 Companies.
Father : 78 years (retired) Chandigarh, Mother - 74 years.
Brother: 34 Army Sisters: 50/44 years Children.
Sons - 30 BE/MBA (married) - 23 BE (Chem).

Patient as a person:.

Obese = 83 kgs.
Easy Ecchymosis Dandruff, Itching, Hair falling +++ (past thick hair).
Perspiration +++ . Oedema - legs.
Acidity, flatulence < Chillies.
Appetite - N. Cravings - sweets.
Deliveries: 2, both dry labour. Water bag burst

Chief Complaints:

Location Sensation & Pathology
(Area, Direction,Spread, tissue,Organ System &Duration)

FACE since Feb 85 Molluscum, tiny umbilicated,
Forehead < whitish 100+ Itching ++
NECK since 1980
Neck to arm 1/month.
for 5-6 days Pain spondylosis
Last 13.9 for 4 days
2. Gen BP 150/100
3. Head Pain 1/2 sided.
1/w for 2 days Band like
4. Thyroid since 1981 Palpitation sweat.
Hyper to Hypo Pulse+
5. Mind since 1980 Depression, Palpitation, Rest
Modalities Concomitants
AF, < >
< night Allopathy and Homoeopathy, failed > cold so far
< lying
< walking few steps
> hot bath
< afternoon
< night sleep during
< exertion, < climbing
> Rest.

AILMENTS FROM menopauses

Life story:.

Patient was very loquacious and it was difficult to obtain the history in a clear fashion.

1930 - Born Amritsar. Eldest of 3 children therefore always respected. Father - Army, strong discipline. Otherwise patient.
1952 - BA
1954 - Married. Sons in 1955 & 1962
1970 - Gall bladder disease
1977 - Diabetes
1981 - Hyperthyroid - radioactive Iodine - Hypothyroid
1983 - Got elder son married to a girl from poor family, thinking she will be more caring and adjusting. Idea backfired. Girl had never seen money and went berserk in spending. Discos, parties and what not. Did not get along with mother-in-law. Cajoled father-in-law into giving separate house. Eventually took the husband away to USA, where now settled. The whole episode upset patient tremendously.
Repertorial Totality:.
Hot patient.
< sleep during afternoon & night.
AILMENTS FROM Mortification.
AILMENTS FROM Suppressed emotions - anger, jealousy.
Menopause <.
Obesity.
Ecchymoses.
Craving : Sweets
Differentiation of Remedies:.
This patient has shown tremendous.

1. Patience in Homoeopathic treatment.
2. Anxiety is marked but she does not panic.
3. Competent, Husband describes her as Hitler but since he is a

Schizo, he has to be discounted.
Lyco - Cr Sweets. Competent.
Lach : Loquacity, Ecchymoses, sleep <
Planning and programming.
Acute : Bryo 200.
constitutional : Lach 30.
Intercurrent : Tub-b 1M

Follow up:.

17.1.85 Tub-b 1M dose.
23.9.85 was > now feverish & headache. Tongue coated.
Block nose. thirst +++ Bry 200-QDS.
30.10.85 Sneezing with medicine. Pain > Itching Scalp, Shoulders Tub b 10m - 1 dose.
6.11.85 Pain > + warts 4 dry Lach 30 - 1 dose.
14.11.85 Warts bursting.
29.11.85 warts bursting fast. Lach 30 -1 dose.
1.2.86 All warts gone.

The main complaint this patient came for, cleared up fast. Patient has continued to take treatment for something or the other. 2 years later when her husband came to me for Schizophrenia, her whole life story came out. She had never told me about the husband. The shock, total suppression of emotions, the devastation she must have gone through was now clearly visible. She was operated for Gall bladder in 1991. On the table they found she had Cirrhosis of liver and could not operate the Gall bladder. Did not give her much time to live. She has survived 6 years with Liver profile remaining the SAME. She has been given many liver remedies like Card-in, Chelidonium, Lyco, Chin etc. My aim in this case is not to cure her but rather - PREVENTION OF PROGRESS OF CIRRHOSIS.

This demonstrates limitations of treatment. Expectation of a physician should be in accordance with the state of the disease. All cases cannot be miraculously cured.

Case 2:

ILLUSTRATES - How "H" helped a 65 year old man get rid of his life long obsession of avoiding cold drinks and wrapping himself warmly, even in the moderate climate of Mumbai.

He came on 14.2.94 complaining of

Pernicious colds, every 2-3 months, Begins with irritation and pain in the throat, coryza, sneezing, followed by hoarseness.

Cold are brought on by smoke, change of weather, pesticides, even dyed shirt, cold drinks and ice creams. Better by warm drinks & Vitamin C.

Other complaints - Hypertension, takes allopathic medicines daily.

- Acidity - eats out which give pain and burning.

(R) shoulder pain since Jan 94, worse in winter and monsoon, makes it difficult to even put on a shirt. Pain better - Physiotherapy Orthopaedic opinion - Old fracture Adv - Inj Hydrocortisone No relief.

Patient as person:-.

Lean and tall, 5 10" 62 kgs. Always decently dressed.
Wife - Obese, sloppily dressed.
Hair - light grey.
Eyes:- Spectacles, pouches under the eyes.
App. N; Craves - meat, fish vegetables
Aversion - Sweets.
Flatulence - often after fibre veg.
Youngest of 10 children (6M/4F) Very close to brother 1 & 3.
Father civil engineer.
Eldest brother in Europe for 30 years.
Son - 32 years, job in foreign bank at Canada.
Daughter - 27 years
Both well educated, working and married.

Mentals :-.

Very Impatient, Irritable 3 egoistic 3, very few close friends, very much involved in work. Now 65 years works as consultant, after retiring. Very fastidious, sets high standards.
Therefore constantly dissatisfied.
Likes wearing old and comfortable clothes.
Sleep : Poor, dreams often about work.
Planning and programming.
The remedy clearly emerges is Nux - v which helped him to some extent.

ACUTE : Rhus tox / Nux-vom.
CONSTITUTIONAL : SIL (decided later on)

Essential Totality Repertorial Totality

1. Self made SR 411 1. Will Strong
2. Hard working SR 118 2. Busy
3. Dominating SR 398 3. Dictatorial
4. Ego3 SR 438 4. Egotism
5. Fastidious SR 472 5. Fastidious
6. < Contradiction SR 184 6. Contradiction.
   (in tolerance of)
7. Impatient SR 604 7. Hurry in Ph 188
8. < Sun, < Monsoon,.
   < Winter K 1404 8. Sun agg.
   K 1421 9. Wet weather agg.
   K 1422 10. Cold weather agg.

Follow-Up

14.2.94 Nux-v 200 3 doses
17.2.94 Reported >
23.2.94 Again + S L
2.3.94 > exc heaviness abdomen
14.3.94 Cold, fever AILMENTS FROM Indore Nux-v 200 TDS
29.4.94 Again feverish Nux-v 1M (1)
13.5.94 Again feverish Repeat
13.6.94 Got wet cold with L shoulder pain Rhus-tox 30
4.7.94 Better except shoulder pain Which was treated with Acute remedies with no relief. Rhus tox 200 - 1M, Nux v till 50M, Guaiacum 200 - 1M.
3.4.95 I reviewed the case. He was much better but bad throat once a month continued, Shoulder pain was not better.
New symptom : Dark brown pant < Phatak Rep colour. bright < Sil I carefully went through Sil All Other symptoms, like recurrent colds etc. also fitted in the picture, Sil 200 (1).
17.4.95 Better +++ Shoulder also slightly better.
With Sil monthly doses, gradually increasing the potency, he is free from cold for 6 month stretches. So too the shoulder pain. His life has undergone a sea of change. He does not wrap himself warmly at night or in open air. Nor is he constantly protective.

Case 3:

Mrs. BES 23 years, petite & pretty, walked in on 25th Dec 95, with her husband who is also our patient, who that day, looked positively handsome.

C/C - Weakness, Occasional blackouts, anaemia, Backache with Leucorrhoea, Hyperacidity, Oedema feet & face.

Patient as a person:.

5, 49 kgs. Ecchymoses easy, Hair fall, few grey hair, cold palms and soles. Oedema feet & face.
Perspiration 3 -- profuse, offensive, leaves stains.
Appetite - Poor.
Cravings - Sour3, cold drinks, sweets 2.
Menses 3/23,.
Menses before - Pain things, Hips.
Hot patient.

Life story:.

Father in metal business. She is the only daughter with 4 sons. Brought up by grand parents. Very attached to family, very protected. Very nervous and anxious at anything new. Married at 19 years & had to immediately look after ailing mother-in-law and run the house. This reversal of roles (cared for => caring) and unusual responsibility led to poor sleep and ill health.

Essential Totality:

1. Irritable
2. Anxiety Anticipation
3. Fastidious
4. Debility
5. Leucorrhoea with backache
6. Backache in pregnancy
7. Offensive perspiration
8. Perspiration stains
9. Oedema face

Repertorial Totality:

1. SR 187 Contradiction Agg
2. K 4 Anxiety, Anticipation from
3. SR 472 Fastidious
4. BB 69 Debility < leucorrhoea
5. BB 690 Backache < leucorrhoea
6. BB 802 Backache < pregnancy
7. SR 11 503. Perspiration, offensive
8. SR 11 511. Perspiration, stains
9. K 392 Face, oedema.

Remedies from Repertorial filter

Puls 6 power 19
Chin 6 " 16
Lyco 6 " 16
Calc c 6 " 15
Kali c 5 " 13
Ars 5 " 12

To Differentiate

Puls 6 power 19 - Leaning. Anxious. Weepy, Fastidious. - but physical symptoms = not matching
6 power 15 Nux-vom
6 power 15 Calc-c
5 power 13 Kali-c - High Anxiety. Debility. Oedema. Leuc + Backache. Irritable
Graph 6 power 16 - M + P excessive. Graph obese.
Symptoms match, but not so much irritability and
Graph is more meek, also obese. Final choice = Kali carb.

Follow up:

21.12.95 Kali-c 200 1 dose
3.1.96 >, Leuc 20 percent > Kali-c 200- 3 doses
25.1.96 > +++. No Leuc. Back >.
No weakness, no Acidity,.
Sleep >. Oedema > MP >
May 1996 Message saying that she is well.

Case 4:

1995 May. 2 sisters brought for primary infertility. 2 personalities more diverse than are difficult to imagine. Our patient was like a china doll, petite & pretty, so delicate & slim that, though 28 years, looked more like 18 years. From a family of fashion designers both sister, mother and husband of the patient, were well known dress designers.

Patient as a person:

Ht 5 3" Wt. 40 kgs., easy ecchymoses recent hair fall <irregularity in menstrual period.
Perspiration - less
Appetite - N
Craving - Sour, Sweets, Salty, Cold drinks.
Bowels - Once in 2 days. Patient not uncomfortable.
Chilly patient likes sun and brightness.

Menstrual History:

FMP - 13 years; 4/30
Now since Jan 95 4/45; since decided on getting pregnant. Also since then Menses before < Fullness abd. Frequent urine. heavy / Tender LMP - 23.8.95

Chief complaints:

Location Sensation Modalities Concomitants
Chest from 1985 Palpitation Af Diarrhoea Fear
1/2-3 months for Low BP Dehydration Last 1.9.95 for Suffocation, < AM, On walking
4 hours weakness, fainting > Loose clothings.
and cramps
Palms 1/month Cramps Numb stiff > AC Lying down.
< AM.
> Day

Life story:.

Born 67 younger of 2 sisters. After XIth did fashion designing. Spent 2 years at Delhi & then set up shop in Mumbai (92). Met a co-designer and decided to marry in 93 (She a Sindhi; he a Muslim) Fairy tale wedding. Joint family setup. Mother-in-law doing most house work. Brought bigger house after brother-in-laws marriage, since they all wanted to stay together. But while flat was being renovated each unit of the family lived separately with relatives etc. Became closer to husband as leaving alone, for interim period.

Mentals:.

Soft, Loving, Timid, Likes to flow smoothly without major fights or confrontations.
Is delicate and likes to be taken care of. A little apprehensive of responsibility, maybe that is why the delay on deciding to have a baby, Periods => Irregular.

Essential totality:

Avoids confrontations
Loves travel / clothes
Affectionate Leaning
Loves company Calm
Fear alone Artistic
Palpitation Chilly
< Tight clothes
Suffocation
Menses late
Menses before - frequent urine
Cravings Sweets, Cold Sour

Repertorial Totality:

1. SR 13 Affectionate
2. SR 650 Indecisive
3. SR 810 Calm, Quiet disposition,
4. SR 1023 Timidity
5. SR 149 Company loves
6. SR 150 < Alone
7. SR 1030 Travel Desire
8. SR 574 Helplessness, feeling of
9. K 1348 Cold in Gen Aggravation
10. K 873 Palpitation
11. K 839 Oppression
12. K 727 Menses late
13. BB 677 Menses before < urine

Remedies that emerged:

Phos 14 power 37
Ars alb. 12 power 29
Puls 10 power 25
Sil 10 power 14
Lach 11 power 20

Discussion:

A very clear Phos case, Lach came up for differentiation, because of night < and tight clothes <, But the subdued nature went against it.

Planning and programming :.

Constitutional : Phos
Intercurrent : Tub-lb

Follow up:

15.9.95 Phos 200 - 1 dose
29.9.95 > 3, even started passing stools daily tub-b 1M 1 dose
10.10.95 > No MP 6 weeks Phos 200 2nd dose
17.10.95 Well. Relaxed. Pregnancy test Negative. Phos 200-3rd. dose
27.10.95 MP 24.10 after 2 months - SL
17.11.95 Well - SL
27.11.95 Well Occ. Palpitation No MP Phos 1M 1 dose
19.12.95 MP 3.12 (3/41 days)
22.1.96 Wt. 41 (1 kg+) MP 2.1 (2/30)
19.2.96 MP 9.2 (4/37 days)
18.3.96 No MP. Pregnancy test Positive

CONGRATULATIONS TO HER AND TO US!

17.5.96 Occ tired. Diarrhoea Green Phos 1M - 2nd dose
29.5.96 Tired Tub-b 2nd dose 1M as an antimiasmatic.
Overall well. Happy pregnancy, doing well. During Pregnancy all miasmatic stigmata to be removed by Anti-miasmatic remedies. In Dec 96 she delivered a healthy baby.

Conclusion :

I hope these detailed cases give a clear idea of the reasoning that goes into every case at all levels - Case taking itself, the working out of the case and the Follow up. This systematic Approach to a case is more scientific : which means easier to reach and to repeat. A good scientific experiment is one which can be repeated with the same results. So too go homoeopathic reaching.

1. It allows you to train students
2. It allows you to repeat results and give good cures consistently.
3. It allows clear and concise thinking.
4. Artistic approach develops gradually when scientific approach is practiced is consistingly.

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