Case taking outline

The patient's story

Let the patient talk until they run out of things to say.

Modalities 

Apply the following to each of the symptoms gathered so far in the following order:

• Causes


• Prodrome, onset, pace, sequence, duration


• Character, location, laterality, extension and radiation of pain or sensations


• Concomitants and alternations

Aggravation or amelioration

• Time (hour, day, night, before or after midnight); periodicity; season; moon phases


• Temperature and weather: Chilly or warm blooded usually, chilly or warm blooded in present illness; wet dry cold, or hot weather; weather changes; storm or thunderstorm (before, during or after); hot sun, wind, fog, snow, open air, warm room, changes from one to other, stuffy or crowded places; drafts, warmth of bed, heat of stove, uncovering


• Bathing (hot, cold or sea), local applications (hot, cold, wet or dry)


• Rest or motion (slow or rapid, ascending or descending, turning in bed, exertion, walking, on first motion, after moving a while, while moving, after moving), car and sea-sickness


• Position: Standing, sitting, (knees crossed, rising from sitting), stooping (rising from stooping), lying (on painful side, back, right or left side, abdomen, head high or low, rising from lying), leaning head backward, forward, sidewise, closing or opening eyes, any unusual position such as knee-chest


• External stimuli: Touch, hard or light, pressure, rubbing, constriction (clothing, etc.), jar, riding, stepping, light, noise, music, conversation, odors


• Eating: In general (before, during, after, hot or cold food or drink), swallowing (solids, liquids, empty), acids, fats, salt, salty food, starches, sugar and sweets, green vegetables, milk, eggs, meat, fish, oysters, onions, beer, liquor, wine, coffee, tea, tobacco, drugs


• Thirst, quantity, frequency, hot, cool or iced, sours, bitters, etc.


• Sleep: In general (before, during, on falling asleep , in first sleep, after, on


• Menses (before, during, after, or suppressed)


• Sweat: Hot or cold, foot-sweat, partial or suppressed.


• Other discharges: Bleeding, coryza, diarrhea, vomitus, urine, emissions, leucorrhoea, etc.; suppression of same


• Coition, continence, masturbation, etc.


• Emotions: Anger, grief, mortification, fear, shock, consolation, apprehension of crowds, anticipation, suppression of same

Strange, rare and peculiar symptoms

Pull these symptoms out when possible.

The patient as a whole

Physical generals

• The constitutional type of the patient (endrinologico-homeopathic correspondences, lack or excess of vital heat, lack of reaction, sensitiveness, etc.)


• Ailments from emotions (see also mental generals); suppressions (emotions; discharges such as menses, sweat, leucorrhoea, catarrh, diarrhea, etc.; eruptions; diseases such as malaria, rheumatic fever, exanthemas, syphilis, gonorrhea, etc.; of pathology such as hemorrhoids, fistulae, ulcers, tonsils, tumors, other surgical conditions, etc.); form exposure to cold, wet, hot sun, etc.; from mechanical conditions such as overeating, injury, etc.


• Menses, date of establishment, regularity (early or late), duration, color, consistency, odor, amount, clots, membrane, pain (modalities of), concomitants, aggravation or amelioration before, during, or after, both physically and mentally, menopause (symptoms of)


• Other discharges (see above) 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 (before, during, or after)


• Sleep, better or worse from, position in, aggravation after, difficulty in getting to sleep, waking frequently or early, at what hour, somnambulism, talking in sleep, dreams (see Mentals), restless during


• Restlessness, prostration, weakness, trembling, chill, fever, etc.


• Aggravations and ameliorations applying to patient as a whole as above.


• Objective symptoms such as redness of orifices, superfluous hair, applying to patient as a whole


• Pathology which applies to patient as a whole, such as tendency to tumors, wens, cysts, polyps, warts, moles, individual and family tendency to certain diseases or weaknesses of specific organs or tissues (also related to a. above and to physical examination), frequency of catching cold

Mental generals

These are studied last for convenience.

• Will: Loves, hates, and emotions (suicidal, loathing of life; lasciviousness, revulsion to sex, sexual perversions; fears; greed, eating, money, emotionality, smoking, drinking, drugs; dreams; homicidal tendencies, desire or aversion to company, family, friends; jealousy, suspicion, obstinacy, contrariness, depression, loquacity, weeping, laughing, impatience, conscientiousness)


• Understanding: Delusions, delirium, hallucinations, mental confusion, loss of time sense


• Intellect: Memory concentration, mistakes in writing and speaking

Quick review

of condition of every systems and organ, beginning with head and following order of Kent's Repertory

Past history

of patient in seven-year periods

Family history

Physical examination and laboratory tests