Effective Case Taking
By Julius Wambua
Homeopath, Acupuncture technician and Nature Cure
Basic Guidelines on Case Taking

Study never ends; know more than your patient!
 Make
use of internet resources & phone apps
 Homeopathic
sites to study new articles
 Homeopathic
mailing lists to learn and discuss cases
 Drugs.com
to study allopathic drug side-effects and uses
 Study
diseases & symptoms
 Study
other support therapies for different diseases
 Study
more about nutrition and how to apply it
A
new remedy every week
 Continue
studying diseases & physiology
Basic Guidelines on Case Taking

Remember the basics don’t get out of fashion.
 CLAMS
• Concommitants
• Modalities
• Location
• Aetiology
• Sensations
 Generals,
Particulars, Mental-Emotional,
Rare & Peculiars
 Timeline
& Aetiology
 Environment,
Social relationships, Lifestyle,
Family History
Basic Guidelines on Case Taking

Let the patient talk, then ask after

Don’t just assume the disease just because the
patient called it “…”. Confirm for yourself what’s
really happening

Don’t get satisfied until you fully understand

Dig, dig, dig until you uncover the aetiology

Keep the repertory open on the main sx’s to get a
few hints on more questions to ask
Basic Guidelines on Case Taking

Capturing the Aetiology or the Miasm can solve the
whole case, so keep at it until you’re satisfied

Past history
 TB,
Cancer, STD, Hiv?
 Surgeries
 Family
 Social
planning
history… smoking, alcohol, drugs, sexual
 Vaccination
history
Basic Guidelines on Case Taking

Physical observations are a great help:
 Skin
 Blood
pressure & pulse
 Weight
 ENT
 CAJCOLDD Cyanosis, Anemia, Jaundice, Clubbing, Oedema,
Lymphadenopathy, Dyspnea, Dehydration
 Lungs
 Kidney and Abdominal palpation
Basic Guidelines on Case Taking

Constitution

Miasm

Personality

Emotions
Basic Guidelines on Case Taking

The 5 C’s of mental outlook or
personality traits
 Company
 Consolation
 Confrontation
 Contradiction
 Criticism

How a person deals with these Cs
is a window to their personality.

How do you manage yourself when in …
circumstance?
Basic Guidelines on Case Taking

6 major emotions
 Grief
(sorrow, lost love, loneliness)
 Anger
 Fear
(irritation, vexation, rage)
(foreboding)
 Anxiety
(panic, worry)
 Humiliation
 Depression

(shame, embarrassment)
(sadness)
Anger, Anxiety, Fear, Depression are most
often secondary reactions to a deeper layer.

What are you thinking about when you feel … ?

So what if … happened? What would it matter?
Case Taking Guide
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 aetiology (if any)?
6.
Did you capture the generals: sleep, temperature, appetite & food habits;
libido or overall energy?
7.
Did you capture the CLAMS of the major sx: concommitants, location (exact),
aetiology, modalities, sensations?
8.
Describe what is happening on the mental level with this patient?
9.
What are the mental /emotional and generals sx related to the disease or
pathological state?
10. What
are the mental /emotional and generals sx related to the general
personality?
Case Taking Guide
11.
Have you uncovered any rare, peculiar or outstanding sx or observations?
12.
Have you made a physical examination of the patient? BP, Cajcold, ENT,
organs, etc
13.
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?) Have you tried looking it up in clinical books?
14.
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, < cold, feeling the bed is hard are sx of the individual)
15.
If the patient has told you a number of confusing sx, which sx are affecting the
vital force the most?
16.
If the patient has told you a number of confusing sx, did you ask “which of
these pains (sx) disturbs you the most?”
17.
Have you double-underlined critical or important sx, observations or words of
the patient throughout the case?
18.
Have you checked or referred to the repertory for further hints to what you
must ask the patient?