Dr Puneet Kumar Misra
Abstract – Dr Samuel Hahnemann the founder of homoeopathy in year 1833 5th edition of “ORGANON OF MEDICINE” mentioned the direction of assessment(case taking) of ill person in the aphorism 83 to 104 and it unchanged in the 6th edition and till today . The issue of the assessment of an ill person is a very crucial task and it needs technical skill, scientific knowledge, and human understanding. But currently Extraordinary advances in biochemistry, cell biology, immunology, and other with newly developed imaging techniques, provide a full window into the most remote recesses of the body and allow access to the innermost parts of the illness. The details of the ill person assessment are extensively present in the different book of Practice of Medicine and when we closely assess it then we found the in the 1833 Dr Samuel Hahnemann opinion and currently available details in the Practice of Medicine are vary identical.
Key words – Case Taking, Organon of Medicine, Practice of Medicine, illness.
Abbreviation– NEWS – The National Early Warning Score, SE – systems enquiry, AMU-admissions unit or acute medical unit , B.T.P.B. – Boenninghausen’s Therapeutic Pocket Book
This individualizing examination of a case of disease, for which I shall only give in this place general directions, of which the practitioner will bear in mind only what is applicable for each individual case, demands of the physician nothing but freedom from prejudice and sound senses, attention in observing and fidelity in tracing the picture of the disease 1
When the patient (for it is on him we have chiefly to rely for a description of his sensations, except in the case of feigned diseases) has by these details, given of his own accord and in answer to inquiries, furnished the requisite information and traced a tolerably perfect picture of the disease, the physician is at liberty and obliged (if he feels he has not yet gained all the information he needs) to ask more precise, more special questions. 1
While inquiring into the state of chronic disease, the particular circumstances of the patient with regard to his ordinary occupations, his usual mode of living and diet, his domestic situation, and so forth, must be well considered and scrutinized, to ascertain what there is in them that may tend to produce or to maintain disease, in order that by their removal the recovery may by prompted.1
When the totality of the symptoms that specially mark and distinguish the case of disease or, in other words, when the picture of the disease, whatever be its kind, is once accurately sketched, the most difficult part of the task is accomplished. The physician has then the picture of the disease, especially if it be a chronic one, always before him to guide him in his treatment; he can investigate it in all its parts and can pick out the characteristic symptoms, in order to oppose to these, that is to say, to the whole malady itself, a very similar artificial morbific force, in the shape of a homeopathically chosen medicinal substance, selected from the lists of symptoms of all the medicines whose pure effects have been ascertained. And when, during the treatment, he wishes to ascertain what has been the effect of the medicine, and what change has taken place in the patient’s state, at this fresh examination of the patient he only needs to strike out of the list of the symptoms noted down at the first visit those that have become ameliorated, to mark what still remain, and add any new symptoms that may have supervened. 1
METHODS OF REPERTORIZATION – Boenninghausen’s Characteristics and Repertory has got its own advantages over other repertories. It is well explained, well arranged, follows a definite plan and construction, and based on a sound philosophy. Adequate acquaintance with the repertory is needed to put it to maximum use. Boger has given greater importance to causation, time-dimensions, modalities and generals (pathological, physical and mental). The repertory can be used by following the methods mentioned below which allow us to use it in different cases of different dimensions with individual pictures. Therefore, it is the case which decides the method to be applied to select the similimum, not the physician. It is a highly qualitative approach, and hence any kind of manipulation or twisting of data should be strictly avoided. Mental state should be used for final selection of the drug in all the methods given below. Selection of method is entirely based on the availability of data in a case. 2
- Using causative modalities in the first place – this method would be useful if the case has definite causative modalities and other expressions, which are arranged below according to the hierarchy. CAUSATIVE MODALITIES (A.F.) Mental and physical. i.e. Fear, excitement, getting wet etc. OTHER MODALITIES AGG. – Mental – Physical AMEL. – Mental – Physical PHYSICAL GENERALS CONCOMITANTS LOCATION & SENSATIONS . 2
- Using modalities in the first place Sometimes we find that case is not presented with causative modalities, but it has other general as well as particular modalities; such cases can be repertorized by using the following order. MODALITIES – Mental – Physical CONCOMITANTS PHYSICAL GENERALS LOCATIONS & SENSATIONS 2
3.Using concomitant( concomitant is the major contribution of Boger to the Homeopathic system of medicine. He has worked hard to collect concomitants from different sources namely, proving, clinical experience and verifications which were not accessible to thc profession earlier. This is a valuable addition for the purpose of repertorization.) in the first place in some cases, if clear concomitants are available even without any modalities, such types of cases can be successfully repertorized with the help of this repertory by following the order given below. SENSATIONS AND COMPLAINTS CONCOMITANTS PHYSICAL GENERALS LOCATIONS ETC. 2
- Using pathological generals these are the changes in the tissues at different Locations in a person, which follow a pattern; thus they show the expression of deviation in the constitution and it is very important in erecting a totality. Following order should be followed. In such cases the pathological generals may be the most important symptom. PATHOLOGICAL GENERALS PHYSICAL GENERALS CONCOMITANTS (weak concomitant) MODALITIES . 2
- Using diagnostic rubrics Boger has contributed many clinical conditions in the repertory and they can be used when the case is not having any other choice, or if the case is lacking in characteristic expressions. This helps mainly in finding out a palliative drug, or drug which is suitable in helping to overcome the present crisis. It should be arranged as follows: CLINICAL RUBRIC AGGRAVATIONS AMELIORATIONS CONCOMITANTS (weak concomitant) PHYSICAL GENERALS . 2
- Following Roberts’s( B.T.P.B.) method LOCATIONS SENSATIONS MODALITIES CONCOMITANTS PHYSICAL GENERALS Here Sensations and Modalities are first referred to the parts concerned. In case the particular Sensation and Modalities are absent they can be referred to in the General chapter. If General Modalities are represented well (i.e., if rubric contains more number of medicine), they should be used for the purpose of repertorization. 2
- 7. Fever totality In a fever case, if the stages (Chill, Heat, Sweat) are distinct, the following order would be preferable; if some stage is not available in the case, only the next stage should be used for repertorization.
CHILL Type/partial chill/coldness-partial/shivering Time Aggravation Amelioration Concomitant HEAT Type/partial Time Aggravation Amelioration Concomitant
SWEAT Type/partial Time Aggravation Amelioration Concomitant Pathological types of fever mentioned in the repertory can be used for reference and final selection of the drug, but more importance should be given to the repertorial result which is obtained by following the above order. Sometimes these rubrics (pathological types) can be used by following 5th method mentioned earlier. Section on blood circulation (congestion, palpitation, heartbeat, and pulse) should be used if symptoms are prominent during any of the stages of fever. 2
- Use of Concordance chapter This chapter deals with the relationship of remedies. The chapter can be used by following the same method, which is used in working out of “Relationship of Medicines” in Boenninghausen’s Therapeutic Pocket Book. 2
- It can be used for studying the relationship of remedies at various levels – mind, parts, sensations, modalities.
- It helps to find out a close running medicine, which can be thought of in future follow-ups if picture changes.
- To find out a second medicine, if the first one (though – indicated), does not meet the expectation in given time.
- Sometimes a deep acting medicine, though indicated, should not be given so as to avoid unwanted precipitation of adverse symptoms; in those cases an analogue can be found out with the help of this section.
- This section helps us to study various relationships of remedies. Kent has suggested a close study of sub headings and medicines listed against them. A remedy, which runs throughout in higher marks, bears a definite relationship with remedy, like Aconite and Sulph, Puls with Sil. and Kali sulph. 2
Method of working: When the indicated medicine has helped a little and when there is no further improvement without much change in the presentation the section can be referred to for finding out a close medicine which would help the patient. Under the medicine (first prescription) refer the sub-heading which could be the main complain of the patient and use it as the first rubric. Next, take Mind and all other sub-headings one after another. The first rubric can be used as an eliminating rubric (only those medicines would be taken further which cover the first rubric). If it is a case of Tonsilitis – ‘Glands’ could be the first rubric. For headache, it could be ‘sensations,’ etc. 2
History taking Having overcome the strangeness of meeting and talking to a wide variety of people that he might not ordinarily meet, the new medical student usually feels that history taking ought to be fairly simple but that physical examination is full of pitfalls such as unrecognized heart murmurs and confusing parts of the neurological examination. However, the experienced doctor comes to realize that history taking is immensely skilled, and that the extent to which this skill goes on increasing with experience is probably greater than for clinical examination 3
Emergency presentations If the patient is being seen as an emergency, the whole process of history taking is altered according to the surroundings and the degree of illness. No history may be obtainable from a severely ill or unconscious patient, but collateral history from bystanders, relatives or emergency medical personnel should not be ignored. In retrospect this information can be hard to get later on in the patient’s illness and can be crucial to diagnosis (e.g. was the patient seen to have a grand mal seizure, or did he complain of sudden pain, before a collapse). 3
Developing themes This stage of the history is likely to see the patient talking much more than the doctor, but it remains vital for the doctor to steer and mould the process so that the information gathered is complete, coherent and, if possible, logical. Some patients will present a clear, concise and chronologically perfect history with little prompting, although they are in the minority. For most patients, the doctor will need to do a substantial amount of clarifying and summarizing with statements such as ‘You mean that …’, ‘Can I go back to when …’, Can I check I have understood …’, So up to that point you …’, ‘I am afraid I am not at all clear about …’ and ‘I really do not understand, can we go over that again?’ If a patient clearly indicates that he does not wish to discuss particular aspects of the history, then this wish must be respected and the diagnosis based on what information is available, although it is also important to explain to the patient the limitations that may be imposed by this lack of information. 3
Disease-centred versus patient-centred An interview that uses lots of direct questions is often ‘disease centred’, whereas a ‘patient centred’ interview will contain enough open-ended questions for patients to talk about all of their problems and be given enough time to do so. This will also help to avoid the situation in which the doctor and the patient have different agendas. There can often appear to be a conflict if the patient complains of symptoms that are probably not medically serious, such as tension headache, while the doctor is focusing on some potentially serious but relatively asymptomatic condition, such as anaemia or hypertension. In this situation, a patient-centred approach will allow the patient to air all of his problems and will allow a skilled doctor to educate the patient as to why the other issues are also important and must not be ignored. A GP may rightly refuse a demand for antibiotics for a sore throat that is likely to be viral but should use the opportunity to educate and inform the patient about the true place of antibiotic treatment and the risks of excess and inappropriate use. The doctor needs to grasp the difference between the disease framework (what the diagnosis is) and the illness framework (what are the patient’s experiences, ideas, expectations and feelings) and to be able to apply both frameworks to a clinical situation, varying the degree of each, according to the differing demands. 3
A schematic history A suggested schematic history scheme for basic history taking
■ Name, age, occupation, country of birth, other clarification of identity ■ Main presenting problem ■ Past medical history – ‘Before we talk about why you have come, I need to ask you to tell me about any serious medical problems that you have had in the whole of your life’ ■ Specific past medical history – e.g. diabetes, jaundice, TB, heart disease, high blood pressure, rheumatic fever, epilepsy ■ History of main presenting complaint ■ Family history ■ Occupational history ■ Smoking, alcohol, allergies ■ Drug and other treatment history ■ Direct questions about bodily systems not covered by the presenting complaint. There will be many clinical situations in which it will be clear that a different scheme should be followed. An important part of learning about history taking is that each doctor develops his own personal scheme that works for him in the situations that he generally comes across. Nevertheless, it is useful to start with a basic outline in mind. 3
Particular gestures useful in analysing specific pain symptoms ■ A squeezing gesture to describe cardiac pain ■ Hand position to describe renal colic ■ Rubbing the sternum to describe heartburn ■ Rubbing the buttock and thigh to describe sciatica ■ Arms clenched around the abdomen to describe mid-gut colic 3
Words and phrases that need clarification Ordinary English words ■ Diarrhoea ■ Constipation ■ Wind ■ Indigestion ■ Being sick ■ Dizziness ■ Headache ■ Double vision ■ Pins and needles ■ Rash ■ Blister 3
Medical terms that may be used imprecisely by patients ■ Arthritis ■ Sciatica ■ Migraine ■ Fits ■ Stroke ■ Palpitation ■ Angina ■ Heart attack ■ Diarrhea ■ Constipation ■ Nausea ■ Piles/hemorrhoids ■ Anemia ■ Pleurisy ■ Eczema ■ Urticaria ■ Warts ■ Cystitis 3
Bodily systems and questions relevant to taking a full history from most patients. If the specific questions have been covered by the history of the presenting complaint, they do not need to be included again. If the answers are positive, the characteristics of each must be clarified Cardiorespiratory ■ Chest pain ■ Intermittent claudication ■ Palpitation ■ Ankle swelling ■ Orthopnoea ■ Nocturnal dyspnoea ■ Shortness of breath ■ Cough with or without sputum ■ Haemoptysis 3
Gastrointestinal ■ Abdominal pain ■ Dyspepsia ■ Dysphagia ■ Nausea and/or vomiting ■ Degree of appetite ■ Weight loss or gain ■ Bowel pattern and any change ■ Rectal bleeding ■ Jaundice Genitourinary ■ Haematuria ■ Nocturia ■ Frequency ■ Dysuria ■ Menstrual irregularity – women ■ Urethral discharge – men 3
Locomotor ■ Joint pain ■ Change in mobility
Neurological ■ Seizures ■ Collapses ■ Dizziness ■ Eyesight ■ Hearing ■ Transient loss of function (vision, speech, sight) ■ Paraesthesia 3
List of clarifications for a complaint of pain ■ Site ■ Radiation ■ Character ■ Severity ■ Time course ■ aggravating factors ■ Relieving factors ■ Associated symptoms 3
Retrospective history The concept of retrospective history taking is a refinement of taking the past medical history and develops the theme of never taking what the patient says at face value. Many patients will clearly say that they have had certain illnesses or previous symptoms using medical terminology. This information may not be accurate either because the patient has misinterpreted it or because they were given the wrong information or diagnosis in the first place. This area becomes particularly important if any new diagnosis is going to rely on this type of information. For instance, in assessing a patient presenting with chest pain at rest, a past history of angina of effort will be considered a risk factor for acute myocardial infarction and will increase the likelihood of that as the current diagnosis. However, on closer questioning, it might become clear that what the patient was told was angina (perhaps by a relative and not even a doctor) was in fact a vague chest ache coming on after a period of heavy work and not a clear central chest pain coming on during exertion. Clearly the possibility of retaking the history for everything the patient says about his medical past may not be practical in the time available, but the possibility and value of doing this should always be borne in mind and can completely alter the developing differential diagnosis. 3
Analyzing symptoms The objective of the history and examination is to begin identifying the disturbance of function and structure responsible for the patient’s symptoms. This is done by analysis of the symptoms and signs leading to a differential diagnosis .The process of analysis can be likened to detective work, in which the symptoms and signs are the evidence. When a medical student is first faced with the myriad data gleaned on taking a history, he is often baffled as to how to start the analysis, but inevitably the process becomes easier as more medical knowledge is acquired. An analysis of symptoms from a medical student is more based on facts learned from textbooks, whereas an experienced doctor will tend to base the analysis more on patterns of disease presentation that they have encountered many times. While the analytical process is largely acquired through this type of experience, some principles can be described. 3
Hard and soft’ symptoms A detective analyzing evidence of a crime will put a lot of weight on fingerprint or DNA evidence and less weight on identification evidence. The same principles apply to analysing symptoms. A ‘hard’ symptom can be thought of as one which, if clearly present, adds a lot of weight to a particular diagnosis. A ‘soft’ symptom may be thought of as one which is either reported by patients so variably that its true presence is often in doubt, or one which is present in such a variety of conditions as to not be useful in confirming or refuting a diagnosis. Examples of these two groupings are.
‘Hard’ symptoms ■ Pneumaturia: almost always due to a colovesical fistula ■ Fortification spectra: if associated with unilateral headache, strongly suggests classical migraine ■ Rigors: strongly suggests bacteraemia, viraemia or malaria ■ A bitten tongue: if associated with a seizure, strongly suggests a grand mal fit ■ A sudden severe headache ‘like a hammer blow’: strongly suggests a subarachnoid haemorrhage ■ Pleuritic chest pain: strongly suggests pleural irritation due to infection or a pulmonary embolus ■ Itching: if associated with jaundice, indicates intra- or extrahepatic cholestasis
‘Soft’ symptoms ■ Dizziness ■ Light-headedness ■ Tiredness ■ Back pain ■ Headache ■ Wind) 3
Pattern recognition versus logical analysis It is important to realize that in some clinical situations the diagnosis may be clear based on previous experience, and in others the diagnosis has to be built up through a process of logical analysis of symptoms, signs and special investigations. The fact that the process of gaining information from symptoms, signs and special investigations is never completely exact must also be borne in mind so that the patient with an atypical presentation is not assigned the wrong diagnosis. The area of medicine that probably most often uses pattern recognition is dermatology, but recently skin biopsies are used much more to clarify diagnoses that were previously assumed. A patient presenting with chest pain and signs of under perfusion may easily be thought to be having a myocardial infarction but a brief history of the character of the pain (tearing and going through to the back) may prompt a search for a dissecting aortic aneurysm 3
CLINICAL PEARL – A useful mnemonic when taking a pain history is SOCRATES: ● Site ● Onset (sudden or gradual) ● Character ● Radiation ● Associations (other symptoms or signs) ● Time course ● Exacerbating and relieving factors ● Severity 4
IMPORTANT ‘Red flag symptoms’ – these are alarm symptoms which, by their very presence, pattern of behaviour or association with other elements in the history, indicate potentially serious underlying medical conditions such as carcinoma. These symptoms warrant prompt assessment and management. Examples include: ● Haemoptysis alone (?carcinoma, tuberculosis, pulmonary embolism) ● Back pain that is getting worse, lasts longer than 6 weeks, is associated with neurological symptoms such as sphincter disturbance, loss of perianal sensation or progressive motor weakness (?cauda equina syndrome) ● Tight central chest pain lasting longer than 15 minutes, with no relief following glyceryl trinitrate spray, in a patient who has diabetes, hypertension and a history of previous percutaneous coronary intervention (?acute coronary syndrome). 4
CLINICAL PEARL A useful mnemonic for reviewing the PMH/PSH for commonly occurring and serious conditions is ‘MJ THREADS’: ● Myocardial infarction ● Jaundice ● Tuberculosis ● Hypertension ● Rheumatic fever ● Epilepsy ● Asthma and chronic obstructive pulmonary disease ● Diabetes ● Stroke
SE – systems enquiry The systems enquiry is sometimes called the systems review, functional enquiry or review of systems. This is a brief review of symptoms from other systems and therefore a screen for illness elsewhere. Ask about: 4
- General: ● weight ● appetite ● lethargy ● fever ● mood ●
Cardiovascular: ● chest pain ● exercise tolerance ● breathlessness ● paroxysmal nocturnal dyspnoea ● orthopnoea ● ankle swelling ● palpitations ●
Respiratory: ● cough ● sputum ● breathlessness ● haemoptysis ● wheeze ● chest pain ● Gastrointestinal: ● abdominal pain ● indigestion ● dysphagia ● nausea ● vomiting ● bowel habit ● Neurological: ● fits ● faints ● ‘funny turns’ ● headaches ● weakness ● altered sensation ● speech problems ● blackouts ● sphincter disturbance ●
Genitourinary: ● urinary frequency ● dysuria ● polyuria ● nocturia ● haematuria ● impotence ● menstruation ●
Musculoskeletal: ● aches and pains ● joint stiffness ● swelling. If any of the answers are positive, explore them in further detail. 4
DIFFICULT SCENARIOS Despite the best efforts of history taking is not always plain sailing! Occasionally, you will face patients from whom data gathering is difficult. This does not mean that the patients themselves are difficult. Do not be prejudiced or judgemental. Their conduct during the consultation could in itself be explained by their underlying problems. ● Are they having difficulties at home, e.g. financial, relationships? ● Is the problem with the hospital itself, e.g. long waiting times, perceived poor previous experience? ● Are there any medical problems, e.g. psychiatric illness, alcohol or drug misuse? The key to dealing with these scenarios is prompt recognition so that appropriate action can be taken. The angry patient, The reserved patient, The ‘rambling’ patient, The elderly patient. 4
Vital signs Physiological observations are monitored routinely in patients who are admitted to hospital. The vital signs that are measured include heart rate, blood pressure, respiratory rate, oxygen saturations, temperature and level of consciousness. Additional monitoring may include urine output, pain assessment and blood glucose testing. 5
Early warning scores Vital signs are recorded using track-and-trigger systems in the form of early warning scores designed to assess illness severity. Measurements are made of the patient’s respiratory rate, the use of oxygen therapy, oxygen saturation, temperature, heart rate, blood pressure and level of consciousness, and points are assigned for physiological derangement in each organ system. Increased frequency of observations is recommended for patients with abnormal signs, and a rising score triggers a graded response. The early warning score is designed to complement clinical judgment. If you or another member of your team is concerned about a patient, do not dismiss this instinct purely because the early warning score is low. A patient may just look unwell or feel cold to the touch and, although these features are not captured by the early warning scoring systems, they may signify early deterioration, particularly in young patients with greater physiological reserve. 5
The ABCDE approach The ABCDE approach provides a standardized framework for simultaneously assessing and treating life-threatening problems in critically ill patients. This systematic approach will help you to break down complex and stressful clinical situations into more manageable components.
A: Airway If a patient is able to speak normally, you can be confident that the airway is patent. If there is no response or if the patient appears to have difficulty in breathing, perform a more detailed assessment. Airway obstruction is a medical emergency; call for expert help immediately.
B: Breathing It is vital to identify and treat hypoxia, as it can lead rapidly to cardiac arrest and death. Perform a thorough assessment, looking for life-threatening respiratory compromise due to conditions such as acute severe asthma, pulmonary edema or tension pneumothorax.
C: Circulation Consider hypovolaemia as the most probable cause of shock in any acutely unwell patient.
D: Disability Any change in a patient’s conscious level should raise concern. Causes of unconsciousness can include hypoxia, hypercapnia, cerebral hypoperfusion, hypoglycaemia or the use of sedative medications such as opiates. Conscious level is often recorded using the AVPU scale, which categorises the patient as: • alert • responding to voice • responding to pain • unresponsive.
E:Exposure Examine the patient thoroughly while respecting their dignity and minimising heat loss.5
Acute medicine Acute medicine is the part of general medicine that is concerned with the immediate and early management of medical patients who require urgent care. As a specialty, it is closely aligned with emergency medicine and intensive care medicine, but is firmly rooted within general medicine. Acute physicians manage the adult medical take and lead the development of acute care pathways that aim to reduce variability, improve care and cut down hospital admissions. In order to achieve these aims, acute physicians must use their knowledge, combined with high-level clinical reasoning and decision-making skills, to minimize both diagnostic error and the risks of over-investigation 6
The decision to admit to hospital Every patient presenting to hospital should be assessed by a clinician who is able to determine whether or not admission is required. The requirement for admission is determined by many factors, including the severity of illness, the patient’s physiological reserve, the need for urgent investigations, the nature of proposed treatments and the patient’s social circumstances. In many cases, it is clear early in the assessment process that a patient requires admission. In such cases, a move into a medical receiving unit – often termed a medical admissions unit (MAU) or acute medical unit (AMU) – should be facilitated as soon as the initial assessment has been completed and urgent investigations and/or treatments have been instigated. In hospitals where such units do not exist, patients will need to be moved to a downstream ward once treatment has been commenced and they have been deemed sufficiently stable. In suspected cases of airborne-transmissible infectious diseases, patients should be isolated initially and may require cohorting in specific areas of the hospital once diagnoses have been confirmed . Following the initial assessment, it may be possible to discharge stable patients home with a plan for early follow-up (such as a rapid-access specialist clinic appointment) Ambulatory care. 6
CLINICAL SKILLS – History-Taking The recorded history of an illness should include all the facts of medical significance in the life of the patient. Recent events should be given the most attention. Patients should, at some early point, have the opportunity to tell their own story of the illness without frequent interruption and, when appropriate, should receive expressions of interest, encouragement, and empathy from the physician. Any event related by a patient, however trivial or seemingly irrelevant, may provide the key to solving the medical problem. A methodical review of systems is important to elicit features of an underlying disease that might not be mentioned in the patient’s narrative. In general, patients who feel comfortable with the physician will offer more complete information; thus, putting the patient at ease contributes substantially to obtaining an adequate history An informative history is more than eliciting an orderly listing of symptoms. By listening to patients and noting the ways in which they describe their symptoms, physicians can gain valuable insight. Inflections of voice, facial expression, gestures, and attitude (i.e., “body language”) may offer important clues to patients’ perception of and reaction to their symptoms. Because patients vary considerably in their medical sophistication and ability to recall facts, the reported medical history should be corroborated whenever possible.
The social history also can provide important insights into the types of diseases that should be considered and can identify practical considerations for subsequent management. The family history not only identifies rare genetic disorders or common exposures, but often reveals risk factors for common disorders, such as coronary heart disease, hypertension, autoimmunity, and asthma. A thorough family history may require input from multiple relatives to ensure completeness and accuracy. An experienced clinician can usually formulate a relevant differential diagnosis from the history alone, using the physical examination and diagnostic tests to narrow the list or reveal unexpected findings that lead to more focused inquiry. The very act of eliciting the history provides the physician with an opportunity to establish or enhance a unique bond that can form the basis for a good patient–physician relationship. This process helps the physician develop an appreciation of the patient’s view of the illness, the patient’s expectations of the physician and the health care system, and the financial and social implications of the illness for the patient. Although current health care settings may impose time constraints on patient visits, it is important not to rush the encounter. A hurried approach may lead patients to believe that what they are relating is not of importance to the physician, and, as a result, they may withhold relevant information. The confidentiality of the patient–physician relationship cannot be overemphasized. 7
Physical Examination The purpose of the physical examination is to identify physical signs of disease. The significance of these objective indications of disease is enhanced when they confirm a functional or structural change already suggested by the patient’s history. At times, however, physical signs may be the only evidence of disease and may not have been suggested by the history. The physical examination should be methodical and thorough, with consideration given to the patient’s comfort and modesty. Although attention is often directed by the history to the diseased organ or part of the body, the examination of a new patient must extend from head to toe in an objective search for abnormalities. The results of the examination, like the details of the history, should be recorded at the time they are elicited—not hours later, when they are subject to the distortions of memory. Physical examination skills should be learned under direct observation of experienced clinicians. Even highly experienced clinicians can benefit from ongoing coaching and feedback. Simulation laboratories and standardized patients play an increasingly important role in the development of clinical skills. Although the skills of physical diagnosis are acquired with experience, it is not merely technique that determines success in identifying signs of disease.
The detection of a few scattered petechiae, a faint diastolic murmur, or a small mass in the abdomen is not a question of keener eyes and ears or more sensitive fingers, but of a mind alert to those findings. Because physical findings can change with time, the physical examination should be repeated as frequently as the clinical situation warrants. Given the many highly sensitive diagnostic tests now available (particularly imaging techniques), it may be tempting to place less emphasis on the physical examination. Some are critical of physical diagnosis based on perceived low levels of specificity and sensitivity. Indeed, many patients are seen by consultants only after a series of diagnostic tests have been performed and the results are known. This fact should not deter the physician from performing a thorough physical examination since important clinical findings may have escaped detection by diagnostic tests. Especially important, a thorough and thoughtful physical examination may render a laboratory finding unimportant (i.e., certain echocardiographic regurgitant lesions). The act of a hands-on examination of the patient also offers an opportunity for communication and may have reassuring effects that foster the patient–physician relationship. 7
Diagnostic Studies Physicians rely increasingly on a wide array of laboratory and imaging tests to make diagnoses and ultimately to solve clinical problems; however, such information does not relieve the physician from the responsibility of carefully observing and examining the patient. It is also essential to appreciate the limitations of diagnostic tests. By virtue of their apparent precision, these tests often gain an aura of certainty regardless of the fallibility of the tests themselves, the instruments used in the tests, and the individuals performing or interpreting the tests. Physicians must weigh the expense involved in laboratory procedures against the value of the information these procedures are likely to provide. Single laboratory tests are rarely ordered. Instead, physicians generally request “batteries” of multiple tests, which often prove useful and can be performed with a single specimen at relatively low cost. For example, abnormalities of hepatic function may provide the clue to nonspecific symptoms such as generalized weakness and increased fatigability, suggesting a diagnosis of chronic liver disease. Sometimes a single abnormality, such as an elevated serum calcium level, points to a particular disease, such as hyperparathyroidism. The thoughtful use of screening tests (e.g., measurement of low density lipoprotein cholesterol) may allow early intervention to prevent disease . Screening tests are most informative when they are directed toward common diseases and when their results indicate whether other potentially useful—but often costly—tests or interventions are needed. On the one hand, biochemical measurements, together with simple laboratory determinations such as routine serum chemistries, blood counts, and urinalysis, often provide a major clue to the presence of a pathologic process.
On the other hand, the physician must learn to evaluate occasional screening-test abnormalities that do not necessarily connote significant disease. An in-depth workup after the report of an isolated laboratory abnormality in a person who is otherwise well is often wasteful and unproductive. Because so many tests are performed routinely for screening purposes, it is not unusual for one or two values to be slightly abnormal. Nevertheless, even if there is no reason to suspect an underlying illness, tests yielding abnormal results ordinarily are repeated to rule out laboratory error. If an abnormality is confirmed, it is important to consider its potential significance in the context of the patient’s condition and other test results. There is almost continual development of technically improved imaging studies with greater sensitivity and specificity. These tests provide remarkably detailed anatomic information that can be pivotal in informing medical decision-making. MRI, CT, ultrasonography, a variety of isotopic scans, and positron emission tomography (PET) have supplanted older, more invasive approaches and opened new diagnostic vistas. In light of their capabilities and the rapidity with which they can lead to a diagnosis, it is tempting to order a battery of imaging studies. All physicians have had experiences in which imaging studies revealed findings that led to an unexpected diagnosis. Nonetheless, patients must endure each of these tests, and the added cost of unnecessary testing is substantial. Furthermore, investigation of an unexpected abnormal finding may lead to an iatrogenic complication or to the diagnosis of an irrelevant or incidental problem. A skilled physician must learn to use these powerful diagnostic tools judiciously, always considering whether the results will alter management and benefit the patient.7
APPROACH TO THE PATIENT – Patients commonly have complaints (symptoms), but at least one third of these symptoms will not be readily explainable by any detectable abnormalities on examination (signs) or on laboratory testing. Even in our modern era of advanced diagnostic testing, the history and physical examination are estimated to contribute at least 75% of the information that informs the evaluation of symptoms, and symptoms that are not explained on initial comprehensive evaluation rarely are manifestations of a serious underlying disease. Conversely, asymptomatic patients may have signs or laboratory abnormalities, and laboratory abnormalities can occur in the absence of symptoms or signs. Symptoms and signs commonly define syndromes, which may be the common final pathway of a wide range of path physiologic alterations. The fundamental basis of internal medicine is that diagnosis should elucidate the path physiologic explanation for symptoms and signs so that therapy may improve the underlying abnormality, not just attempt to suppress the abnormal symptoms or signs. When patients seek care from physicians, they may have manifestations or exacerbations of known conditions, or they may have symptoms and signs that suggest malfunction of a particular organ system. Sometimes the pattern of symptoms and signs is highly suggestive or even pathognomonic for a particular disease process. In these situations, in which the physician is focusing on a particular disease. 8
- As per Dr Samuel Hahnemann concept of search of disease, it is mandatory to clinician furnished the requisite information and traced a tolerably perfect picture of the disease and then think about the treatment.
- For the perfect picture of the disease at the time of origin of the homoeopathy and currently an marked gap of tools, at the time of the Dr Samuel Hahnemann the window of search is in very narrow, while in the currently Extraordinary advances in biochemistry, cell biology, immunology, and other with newly developed imaging techniques, provide a full platform into the most remote recesses of the body and allow access to the innermost parts of the illness.
- As per need of case Dr Hahnemann’s focus on freedom of clinician and advocacy of liberty for assessment of patient
- In the homoeopathy most of clinicians are depend on the two major subject matreria medica and repartory for the treatment but both subject lack the direction of the assessment of patient , while currently all clinical subject namely practice of medicine ,surgery ,pediatric and other having the direction of treatment along with assessment of ill Patient .in all these subjects practice of medicine play the major role in the direction of the assessment of all case and provide the way of the treatment .
- Repertory provide the similimum medicinal material groups with the severity when we go through the collection of the symptoms during assessment but lack of direction of assessments as per case, and it also provide the information of numbers of medicinal material in a particular illness condition with severity . but pattern of individual Repertory applicability are not mentioned , and no endorsement of new window of detection.
- The Medicine material represent the disease pictures without hierarchy of symptoms or disorder of the disease in the different Materia Medica , but pattern of individual matereia medica applicability are not mentioned, and no endorsement of new window of detection.
- The Practice of Medicine provide the assessment and treatment of modern medicine with hierarchy of symptoms or disorder in the disease with the help of all platform of detections but lack of Repertory and materia medica , and here strong need of development among the association of all three subject namely Repertory , Materia Medica and Practice of Medicine .
- The assessment pattern of practice of medicine currently and 83-104 aphorism given by Dr Hahnemann in the 5th edition in 1833 have marked affinity even then basic tools are vastly changed due to advancement in the medical field.
Conclusion – it is most important issue during the assessment of the person for its illness that clinician apply all process commonly requires a careful history or physical examination, ordering of diagnostic tests, integration of clinical findings with test results, understanding of the risks and benefits of the possible courses of action, and careful consultation with the patient and family to develop future plans. If the physician does not appreciate and address these issues, the science of medicine cannot be applied appropriately, and even the most knowledgeable physician will fail to achieve the desired outcomes. The details shows that at the time 1833 and previous or in current medical science focus on the all aspects of origin of disorder at the time of assessment of patient illness and try to develops the earlier good quality of life
- Dr Samuel Hahnemann. Organon of Medicine by Samuel Hahnemann combined 5th & 6th editions .reprints edition 2007. Delhi: B Jain publishers (p) Ltd; page 127,130,133,139,
- C.M. Boger. Boenninghausen’s Characteristics and Repertory Reprint Edition: 2008 Delhi: B Jain publishers (p) Ltd; 2008.page xlii-xlvi
- Dr Robert Hutchison .Hutchison’s Clinical Methods. 24th Elsevier Ltd; 2018.Page 04-10.
- Dr E Noble Chamberlain .Chamberlain’s Symptoms and Signs in Clinical Medicine. 13th editions . 2010 Edward Arnold (Publishers) Ltd Page 05-10
- Dr John Macleod. Macleod’s Clinical Examination. 14th edition. Elsevier Ltd; 2018. Page 340-346
- Davidson Sir Stanley. Davidson Principal & Practice of medicine. 23nd Elsevier Ltd; 2018. Page 178
- Harrison T. R. Harrison’s Principles of Internal Medicine. 20 Editions. By McGraw-Hill Education; 2018. page 01-02
- Dr LEE GOLDMAN. Dr ANDREW I. SCHAFER. Goldman-Cecil Medicine 26 EDITION Elsevier Philadelphia 2020 . page no 03-04
Dr Puneet Kumar Misra
Lecturer(Practice of Medicine)
Govt Pt J LN H M C Kanpur