Question: I have pain in low back for almost one year now. Following is the details:
CASE TAKING / RECEIVING FORMAT
(This is only a frame work to help you to develop your case. You can expand your case to any extent. But try to help the physician to understand your genetic dispositions, individuality and constitution in the physical and mental plain. )
I PRELIMINARY DATA
1. Name :XXXX
2. Age :42 Years, 11 months
3. Sex :Male
4. Occupation: Working as HR professional with XXXXXXX
5. Financial Status: Good
6. Social status: Good
7. Religion: Hindu
8. Address: C-306, Mahaveer Regal Apartment, Seetharampalya Main Rd. Hoodie, Bangalore
9. Contact no: 0000
10. Email address: YYYY@YYYY
11. Mother tongue: Hindi
II PRESENTING /CHIEF COMPLAINTS
1. Since when the complaints started: June2013
2. Onset sudden or gradual : Sudden
3. Pain –its duration, how long it remains, how it comes and goes, its character, its extension: Moderate/bearable pain is always there, do not find myself flexible to bend down, when I lift heavy objects pain increases
4. Side of affection - Left or Right, from left to right or from right to left, upper left and lower right or upper right and lower left: Left side of lower back goes down to the left thumb of the foot.
5. Aggravating or ameliorating factors or conditions: Aggravates if I lift heavy objects
6. Supportive investigations and reports, diagnosis, findings…:Did not go for any X ray or allopathic diagnosis
7. Speed of development of disease - slow or fast: Slow
8. Probable or final diagnosis : I think is
low back pain , due to lifestyle I work for 8 to 10 hours sitting on chair and using laptop, also drive car 2.5 hours daily.
III ASSOCIATED COMPLAINTS / OTHER DISEASES: NIL
1. Since when the complaints started:
2. Onset sudden or gradual :
3. Pain –its duration, how long it remains, how it comes and goes, its character, its extension:
4. Side of affection - Left or Right, from left to right or from right to left, upper left and lower right or upper right and lower left
5. Aggravating or ameliorating factors or conditions
6. Supportive investigations and reports, diagnosis, findings…
7. Speed of development of disease - slow or fast
8. Probable or final diagnosis
IV PAST HISTORY ( MAJOR ILLNESSES / SURGERIES / ACCIDENTS) IN THE PAST
1. Never well since like
vaccination,
pneumonia,
typhoid,
malaria etc. : No
2. Any suppressive treatment like
ointments for skin,
laser therapy for stones, corrective surgery for eye etc.: No
3. Emotions that precipitate the disease every time: No emotions, its physical whenever I lift heavy objects or bend down it aggravates
4. Emotional conflict happened just prior to the onset of disease that remain unresolved: Nothing, I think it’s the lifestyle where I am working sitting on chair and no physical movements
5. How from lower layers of tissues the disease shifted to more important and higher layers of tissues
6. Chronological journey of disease- how you started with first sickness, next what happened , then what etc. till you developed the present state of illness.
V FAMILY HISTORY / HEREDITARY DISEASE TENDENCIES/GENETIC DISEASES ETC. IN THE FAMILY
1. Father : NIL
2. Mother: Hypertension
3. Paternal Grand Father: NIL
4. Paternal Grand Mother:: NIL
5. Siblings, in order: Hypertension
6. Paternal uncles and aunts: Hypertension, Cardiac
7. Maternal uncles and aunts: Hypertension, Diabetic
VI GYNAECOLOGICAL / OBSTETRICAL HISTORY (FEMALES ONLY): Not Applicable
1. Menses in detail
2. Complaints before, during and after menses
3.
Menarche (onset) age, early, late etc.
4.
Menopause (stoppage ) normal, early, late, complaints during.
5. Children born, living, dead.
6. Abortions, Miscarriages, delivery normal or surgical
VII DRUG / TREATMENT HISTORY
1. Any medication, Allopathic, Ayurvedic or Homoeopatic: No just apply Ortho Oil Homoeopathic and taking Amlopres 5 tab for blood pressure
2. Allergic sensitivity to any drug: No
3. Over use or abuse of drugs: No
4. Any affection / side effects of taking drugs: To the best of my knowledge nil.
VIII INVESTIGATION REPORTS / RESULTS (ATTACH RELEVANT REPORTS)
1. General health: Fit
2. Presenting complaints
IX PATIENT AS A PERSON / PHYSICAL / GENERAL
1. Appearance: built, structure, height, weight, complexion, face, skin, warts, moles, discolouration, pigmentation etc. : 5’6”, 72 Kg, Wheatish towards white complexion, medium built,
2. Speed: of talking, eating, working, walking, Normal speed of taking, little fast when eating and working , normal speed for walking
3. Thermals: Sensitivity to cold or heat, can tolerate heat or cold better, need or fan / ac, need of warm clothes, covers uncovers during sleep, takes warm or cold bath…: I can tolerate heat and cold. Temperature upto 10 deg C I can bear without wollen clothes and comfortable upto 1 deg C with wollens. I can bear temperatues upto 38 deg C without A/C, have comfortably adapted to temp upto 48 dec c without A/c. I generally take bath with lukewarm water all through the year.
4. Appetite: normal, increased or decreased, peculiarities in eating habits, veg/non-ves, desires, cravings and aversions, aggravation and ameliorations, intolerances and ailments from particular tastes and items of food, prefer cold, warm or hot food, :Appetite is normal. I am a non vegetarian and take non veg foods 3-4 meals in a week. I no craving, do not tend to over eat, have no intolerance or aliment or
allergy from any food. I like to try different cuisine. I prefer eating food at room temperature,
5. Thirst: quantity of water drinking in a day, thirsty during night, drinks by habit or by feeling thirsty, during meals only or drinks in between, throat and mouth getting dry, cold or room temperature, warm or hot water, fruit juices, other drinks: I drink around two litres of water in a day. I drink water at room temperature given a choice I like drinking cold water all through the year. I tend to drink two glass of water during the meals. I usually do not feel thirsty during the nights. I have no craving/liking for juices or soft drinks
6. Stool: habits, frequency, difficulties, any complaints before, during, and after. : I go for stool every morning after waking up, its comfortable and I have no difficulty in passing the stool.
7. Urine: any difficulty, any complaint: No difficulty in passing urine.
8. Sleep: sound/ disturbed, deep comatose or catnap- alert, easily waking, restless, tossing about in bed, position in sleep, salivation during etc.: I tend to have 6 to 7 hours of sound sleep every night. Once I hit the bed I get sleep almost instantly, I tend to sleep in one position ( usually sideways on my left side) do not toss around the bed. . No salivation etc. during sleep. Off late I have started
snoring.
9. Dreams: good/ bad, frightful, repetitive, related to family, work, death, dead bodies, accidents etc. : I do not get dreams about accidents, injuries, dead bodies etc. Usually the dreams are around future usually good, nothing frightful/bad.
10. Side: which side is predominantly or frequently affected, : No particular side.
11. Sensitivities: to sun, noise, light, tight clothing, touch, strong or perfume smell, rain, cloudy weather, winds, moon phases etc., how affected and how much…
12. Senses: vision, smell hearing, touch, taste, extra sensory perception etc. . Good sense of vision, smell, hearing and taste. At times on certain situations I feel that this incident has happened with me earlier.
13. Habits: smoking, drinking, chewing etc. : I do not smoke. Or chew tobacco. . I like alcoholic drinks and I am a social drinker, tend to drink 270 ml of alcohol in a week ( spread over three days)
X PATIENT AS A PERSON/ MIND/ LIFE SITUATION
1. Family, single, married, staying together, multiple partners, staying with whom, joint family, nuclear family, mutual relationships etc. : Married staying with wife (housewife 39 years, medically fit ) and two kids daughter 12 years old and son 6 years old. Ours is a nuclear family. My parents have passed away and wife’s father has passed away. Her mother visits us once a year for couple of months.
2. Job, salary, working conditions, job satisfaction, work site conflicts, : Job is good, salary is good and competitive, work conditions are good it’s a high growth company hence the work load is high, satisfied with job, no work site conflicts.
3. Education, diligence for gathering or updating knowledge, eligibility or qualified for the job, laziness to study or to exert mentally, : I have the relevant education/knowledge/skills/capability/competence and experience for the job I am doing. I am open for learning and keep learning through reading, observing and from my mistakes.
4. Expressive or non expressive, extrovert or introvert, vivacious or quiet, loquacious or silent, loud talker, sweet talker, self praise, open hearted, foolish talking, lewd or talking about sex, expansive, changing subjects, talking about money, health, religion, talking to himself, jesting etc. : I am an extrovert, though non expressive about self, a good listener, not a loud speaker, do not brag or self praise, open minded and open hearted, ready to help others, do not speak/encourage open/lewd taking on sex, money, property wealth etc. People in general like taking to me,
5. Communicative, easily starting conversation, easily mixing with strangers, sharing feelings with others, prefers to be in company or solitude: I can start conversation at ease with anyone, no problem in mixing with strangers.
6. Intellect: studied by self, or pushed by others, how handles work, intellectually sharp or slow, concentration and comprehension easy, reading desires, idiocy or childishness, making mistakes while talking and writing, good and quick or bad and slow in making decisions, indecisive or yielding to the opinion of others, etc.: I studied by self, was not forced by parents for study. I am a fast learner, I learn from my mistakes and not repeat them. Quick on making decisions.
7. Diligence or non diligence, regular or not in going to school, work , office etc. : Diligent and regular for going to work and past to school.
8. Morals: respecting rules and morality, sensitive to values: Yes I respect the rules, morality and sensitive to others.
9. Will: good and confident in handling responsibilities alone and in critical situations, or wanting support always, reacting or supporting injustice, strong or weak willed, confident or timid, dependant or courageous, optimistic, persevering and positive or pessimis, bashful or embarrassment.: People call me responsible, strong hearted, supportive, dependent, optimist and high on energy and positive attitude.
10. Memory: good or bad, recollecting events of the past, remembering numbers and names, active or weak , any forgetfulness…: I have a sound memory can re-call incidents about by early childhood with ease. Good in remembering names. Was good in remembering numbers but the smartphones has made be weak on this aspect.
11. Nature or disposition: angry or mild, yielding or haughty, weeping, sarcastic, contemptuous, apprehensive, fearful , contented or discontented , quarrelsome, fighter, revolting or indifferent etc. . : I am generally happy go lucky, contended, composed.
12. Emotions: when getting angry how reacts, anger expressed or suppressed, expressed even to elders, keep thinking about the issue for long or can forget or forgive easily, sentimental or sensitive, sympathetic to the point of forgetting one’s own needs, involved in XXXXXXX or social service, grieved, affectionate, jealousy, rage etc : I don’t loose my cool, when I get angry I express the same but get over shortly. I am forgiving and don’t take matters to hearts. I admit mistakes and tender apologies. Associated with some amount of XXXXXXX and social work.
13. Sensitivity: to behaviour of others, rudeness, criticism, reproach, contradiction of others, relationship, social position, success or failure, money, admonition, ego, appreciation, injustice, to the surroundings, cleanliness mania, nature, animals, music, religion etc. Sensitive towards others, family and friends .Not rude and never criticize
14.
Anxiety about conscience, health, children, family, future, salvation, about trifles, for others, apprehension, anticipation, punctuality, Nil, Generally I am calm, believe in take it easy as it comes.
15. Attachment: to career, position, family, friends, name and fame, money, . I am attached to family , their growth well being, safety and security.
16. Consolation desires, ameliorates, aggravates, appreciation craves, . I don’t have any latent desires, just want to earn enough for a secured life for self and family.
17. Fears: any fixed fear: Does not have any fixed fear. Not very adventurous though.
XI N.B: You can expand the case to any extent for making the physician understand your life situations and your genetic and constitutional reactions to them so that the physician can very easily understand your individualistic and characteristic features, both physical and mental and thus arrive at your curative remedy, the SIMILIMUM.