Check List for Case Taking

[Ananda Ruchira]

Dear Joan,

At 20-01-2004, you wrote:

I put together the below checklist for Case Taking Analysis and Follow Up
Analysis for my fledgling Kenyan students. The purpose of the checklist is
to help check that you've covered all the bases in taking a complete case.
It is not a list such as "Head" "Eyes" etc. (it's assumed you've already
got such a list.) This one is to help you analyse while you take a step
back from the case.

Since we are more physicals/pathological oriented here (vs mentals) there
is more emphasis in that direction. You may want to amend it to ask
yourself more questions along different lines. Of course, too, you'll find
some strange emphasis here and there (eg "is the patient HIV & needs
testing" "have you done a physical exam") - that's peculiar to our
situation (20-35 % of our clients are HIV+ and don't know it)

I print out these 2 checklists on cards so that the students can keep it
next to them while taking the case or while analysing it. It's intended
that you go through it question by question so that you may find the
"holes" in your case taking. Same goes for the follow-up. After a while,
when the questions become ingrained and second nature, you won't need the
checklist anymore.

=======
CASE ANALYSIS GUIDE

Ask these questions to see if you have understood the case you have taken
1. What are you treating? (i.e., a chronic or constitutional
problem, long-term, or a short-term acute disease?)
2. What does the patient want to be treated for? (i.e. the CC: chief
complaint?)
3. What is the centre of the case? or What is the key point that this
case turns on?
4. Have you noted a time-line or a history?
5. What is the etiology (if any)?
6. Have you made a physical examination of the patient? BP, Cajcold,
ENT, organs, etc
7. Describe what is happening on the physical level with this patient?
or What organs or systems are involved? Can you identify the pathology
involved. (i.e. what's the disease?)
8. Have you taken the symptoms of the disease only, or have you gotten
sx of the individual? (e.g.: frequent urination is a diabetes sx, > milk is
a ulcer sx. Being irritable, down ; in-> out
; last -> first).
7. Have the major complaints (CC) improved or only the secondary,
minor complaints?
8. Have some individual parts improved, but there is lowered over-all
energy, generals or mentals?
9. Are you seeing true improvement or only a suppression?
10. Was the remedy well-prescribed and hasn't worked according to
expectation or prognosis?
11. Was the remedy well-prescribed but didn't hold?
12. Could there be a block on the mental level?
13. Could there be a block on the miasmic or causative level?
14. Is there an exciting cause that hasn't been removed?
15. Is progress according to the prognosis or assessment of the last
appointment? Is the prognosis correct? Is the case incurable?
16. Is the remedy acting as expected? Too slow?

If there have been no, or few, changes:
17. Has the patient taken the medicine according to rules? (ie in the
mouth, away from food, not touched it, not with tea or coffee, etc)
18. Has the medicine been compromised or polluted? Has it been
contaminated, exposed, left in sun or heat?
19. Was the Rx correct - the remedy, the potency, the frequency, the
number of days?
20. Is the case-taking faulty? Re-ask more details. Go deeper into the
mental-emotional-generals. Did you uncover any R&P?

STEP 4: FOLLOW UP PRESCRIPTION
1. Read and follow through on the previous assessment and advice(ie
nutritional, herbal support, counselling, etc), Rx, DDx.
2. Consider the Rx, DDx and assessment. Consider the changes and
directions of cure. Consider the blockages.

What to do:

o Wait and watch (optional: give sac lac).
o Don't change the remedy.
o Change the frequency.
o Change the potency.
o Change the Rx. Choose a new Rx based on the DDx,
"related", "follows well" or "complements"; or if necessary "antidotes".
LASTLY:
Advise the patient and bring them up to date on their progress. Encourage
the patient to continue following your advice and congratulate them on
their healing. Write down your assessment, advice to the patient, DDx & Rx
clearly.
Sincerely,
Didi Ananda Ruchira
Director, Abha Light
visit: http://home.pacific.net.sg/~rucira/alf
tel: +254 20 787310 / cell: 0733-895466
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[Sheri Nakken]

THAT IS EXCELLNET
That's a good checklist AFTER the casetaking
Wonderful.
Thank you for that. Your students are really fortunate it appears to have
such an informed teacher
Sheri

At 09:34 PM 01/20/2004 +0300, you wrote:
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Sheri Nakken, R.N., MA, Classical Homeopath
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