Information on the past medical history may have a particularly significant place in diagnostic decision making when there are some concerns about the validity or the reliability of the symptom(s). Patients past history have significance of predictive validity as well as concurrent validity. Trend of adding rubrics related to past complaints are gaining momentum and we find many such are being added not only in generalities and but also in different chapter. This needs to be ascertained for being taken into totality.
Once we have established and assessed the nature of the patient’s presenting problem, there is often a temptation to move straight on to examining the patient or undertaking some preliminary investigations. Diagnostic feature are solely dependent on the as much information as possible looking into the entire aspect of situation promoting the present status of sickness. Patients are usually more concerned with their present problems and try to attract attention of the physician to listen their problem. Every problem has its origin in the past and it needs to find out and relate to know the exact characteristic feature of sickness. It will be essential for a physician to know their previous healthcare, health behaviors, social, occupational and family history.
The additional information in the past medical history may have a particularly significant place in diagnostic decision making when there are some concerns about the validity or the reliability of the symptom(s). Presenting condition of the present illness may have similarity with the many of the patient and may lead to conclusion far away from realistic condition. Present conditions are the reflux state of something happened in the past. It will be useful to know why this present condition aroused.
Significance of Previous History
Patient’s previous history may provide information for diagnostic purposes by providing consideration of – predictive validity and concurrent validity.
Patient usually presents their sickness with the common problem such as back pain, palpitation, constipation, diarrhea or fever. Patients are often concerned about the cause of such condition but there is a persisting controversy regarding the initial evaluation of such patients. Initial reports received from laboratory and other diagnostic methods may not provide significant information. It has been observed that features in the history and examination could be utilized in order to allow the more selective use of laboratory diagnostic tools. Past history can be useful in distinguishing patients with clinically significant common conditions such as arrhythmias in patient presenting complaints of palpitation. Past histories are either positively or negatively associated with the clinical condition. Value of the positive relation represent the likelihood of a clinically condition and at the same time for the negative association more importance is attached to the smaller odds as in these conditions clinical condition can be taken as present aspect with little or no background.
In clinical diagnosis feature beside from use of symptoms such as change in bowel habit or rectal bleeding for colorectal cancer diagnosis it has been suggested that certain pieces of clinical information more readily and uniquely available in past condition such as changes in a patient’s behavior may have significant weights of evidence in assisting the diagnosis of disease. Moreover, it may even be possible to quantify such behavioral changes by looking at alterations in, perhaps, smoking status, consultation patterns, and the use of over-the-counter medications or accompanied surgery attendances.
There are patient who do not visit a physician for many of their conditions such as dyspepsia or constipation, common cough and colds etc. Many a time there are fear for some impending disease like cancer and ignore them yet there are patient who are visiting their consultant for even the trifles. Thus the decision to see a physician is not based simply on the presence or absence of medical problems. History taking in all such diverse state of patient behaviors one has to develop a pattern of case taking which will assist in assisting in developing a totality view of the suffering
Whatever element of the history we are seeking to use for diagnostic purposes, misunderstandings, forgetfulness, cognitive problems such as telescoping and recomposition, and social acceptability biases all need to be taken into account. During case taking often a situation of disagreement occur between the physician and the patient. Some patient denies going for any fresh check up as they had been similarly examined earlier for some of the condition argue that there are no relation between the past and the present condition. Recomposition, in which similar events are brought together as a single event, can be found out with comparison and co-relating the situation. Patients also have bias associated with reporting psychological or sexual issues. With this in mind it is interesting to note that forgetting prior episodes is a common feature in the patients. Minor condition get lost and hence patient often argue for a treating their present condition as new phenomenon
Another specific cognitive bias that may impact on a patient’s description of their previous medical care is the halo effect. This results in one discrete event (e.g. a success or a failure) exerting undue influence (positively or negatively) on the patient’s description and recall of all their care by a specific clinician or hospital. A competent doctor who, through no faults of his own, misses a critical diagnosis may be more generally remembered in a particularly bad light.
In order to assess the concurrent validity of the past medical history, patients needs to be studied about their chronic condition and associated treatment. These data will assist in developing a linkage between the past and present state of sickness. Habituated medicines as in the cases of chronic coronary disease, Hypertension, Diabetes, Arthritis often patient do not feel worth reporting about the medicine like steroids, regular aspirin use. These types of lower sensitivity for reporting needs to have minute’s observation. Educational effect as well as self learned aspect of medical understanding in the patient further creates confusion between the patient and physician Confusion may also occur if the treatment of malignant, pre-malignant and benign conditions is similar. Such factors should be borne in mind when taking a history. For example in seeking to identify patients with ischemic heart disease, episodes of angina and myocardial infarcts should be specifically and separately enquired about.
A serious, novel or unique event in the previous medical history is more likely to be remembered consistently and reliably. For fractures anatomical site and severity appear to aid recall; reports of major fractures such as the hip and wrist are considerably more reliable than reports of finger, toe and rib fractures. Surgery performed in childhood (e.g. tonsillectomy) or regarded as ‘minor’ (e.g. dental extractions) is also likely to be very poorly remembered. It is also important to be aware that different interviewers can elicit different information.
To enhance the concurrent validity in relation to past medication use it will be useful to ask for more specific question about the drug used. Such as if a patient is asked whether he has taken the ATT medicine, he will be recalling the episode of his medical treatment for tuberculosis. Information may also be obtained from the individual’s existing medical records but problems can occur due to time gaps, missing information, ambiguities or inconstancies.
Symptoms, risk factors or personal information are all too often poorly and inconsistently recorded. There may be missing records for the information about smoking, alcohol consumptions or occupation. It will be useful to get the information from relatives or close attendants of the patient. This can be helpful in improving the concurrent validity of the past healthcare history and such information may also be particularly useful if the patient is demented or a minor.
Use of the over the counter medicines like antacids, antihistamines and analgesics or oral contraceptives remain a very personal for the patients. It needs to be clarified by sighting examples. There is also a tendency for proxies to overestimate specific behaviors such as cigarette consumption. In examining the information provided by different proxies it seems that, in general, close relatives – spouse, sibling, parent or child – usually provide more complete data than other proxy respondents.
HEALTH BEHAVIOUR AS PAST HISTORY
Understanding a patient’s health behaviors is important in seeking to reach a diagnosis. Smoking, sexual practices and alcohol consumption can be associated with a number of symptoms and illnesses. Unfortunately patients may over-report what they consider to be socially desirable behaviors and yet under-report apparently socially undesirable behaviors. It will be useful to know the social, economical and family culture in order the get the exactness of the past relativity of conditions. Social behaviors of smoking are often not understood as association of sickness. Parents with smoking habit usually deny that they smoke in front of the children or in the house. But one may smell the tobacco on the cloths of the parent carrying the babies.
Eliciting information about certain sexual behaviors may be more difficult if the patient is accompanied by a child and/or their spouse and/or the doctor is of the opposite sex. It also takes more skilled questioning to extract information about the sexual activity, alcohol consumption or drug use. It will be useful to use the language or phrase used by the patient or with the words they are familiar. Physician needs to be more strategically in addressing a question in these aspects.
TIME CONSTRAINTS DURING CASE TAKING
While it is not ideal, it is often necessary to perform a past medical and minimal social history as part of a focused history and physical exam. This is particularly true in ambulatory care settings where new patients are seen for acute problems without the benefit of a thorough interview. The following is a suggested format for taking a brief past medical history in less than a minute for the average patient. Patients with multiple chronic problems will take longer.
- Allergies and Reactions to Drugs (What happened?)
- Current Medications (Including “Over-the-Counter”)
- Medical/Psychiatric Illnesses (Diabetes, Hypertension, Depression, etc.)
- Surgeries/Injuries/Hospitalizations (Appendectomy, Car Accident, etc.)
- Tobacco/Alcohol/Drug Use
- Reproductive Status for Females
- Last Menstrual Period
- Last Pelvic Exam/Pap Smear
- Birth History/Developmental Milestones for Children
- Marital/Family Status
HOMOEOPATHIC ASPECTS FOR PAST HISTORY
Constitutional homoeopathic treatment consists mainly of prescribing on the psychosomatic make-up of the patient and on the past history. Understanding the Man as a whole is the basic requirement for finding out a constitutional remedy for an individual. Present of a Man is a reality based on the past. Thus to perceive the present totality of a man it is quite necessary to incorporate the past as well as the family history of the patient. The patient is viewed against a background of a theoretical average person of the same age, sex and social environment, and the salient mental and physical characteristics are noted and matched by a remedy having a similar drug picture. One or more, usually a number of remedies carefully chosen in this way can frequently restore health when there are no insuperable pathological barriers. Quite often the psychosomatically selected remedy can cover outstanding episodes in the past.
The patient’s past history and the family history are similarly viewed against the background of a theoretical average family and personal history and outstanding features or events are noted. Then, if psychosomatic prescribing fails to produce satisfactory results, the past history may lead to an appropriate remedy for that individual, or it may be advisable to prescribe on the family or individual history when there are no clear symptomatic indications for any one remedy right from the beginning. Foubister was of the opinion that while “as a rule constitutional treatment can deal with the after-effects of drugs once the drug has been excreted” there are many circumstances where the administration of unproved potentized medicines is justified when selected on the basis of events found in the patient’s history.
Observations on the Homoeopathic Materia Medica
Homoeopathic Materia Medica consists of the records of the symptoms being observed during proving or in clinic. There is often lacking of the associated information that lead to the development of such condition. Thus history of development of symptoms remains hidden as such information often gets misused during prescription. There are no records of any unsuccessful proving , which suggests that all, or nearly all, substances on earth are capable of affecting man in the potentized if not in the crude state; which means that there are several thousand potential homoeopathic remedies as yet untouched. Even if the almost insuperable difficulties of proving and clinically testing were overcome, the addition of so many new medicines would tend to offset any gains by making the already unwieldy and complex material medical so large that it would be virtually impossible for anyone to become familiar with it and the difficulties of remedy selection would be even greater than they are at present.
The only way that appreciable progress can be made through provings is to be able to predetermine the potential value of the substance to b proved. However difficult the problem, much more thought must be given to it. Most recent provings have been almost entirely wasted because there is little incentive to carry out an intensive clinical trial of a remedy which might in the end turn out to be of very little value, although the provings themselves have been carried out scientifically and with the utmost are. Clinical testing is necessary to provide the more important part of the drug picture. In the meantime, obviously the best possible use should be made of the valuable materia medica available, and careful attention to past history is one way by which this can be achieved. Also, in view of the limitations of the proved and tested materia medica, there should be no hesitation in prescribing unproved remedies such as the nosodes of acute disease as occasion demands.
ASPECTS FROM PAST HISTORY FOR HOMOEOPATHIC PRESCRIBING
- Not well since
- Chronic ill-health may follow a severe acute or chronic infection, injury, emotional upset or occasionally, after adverse effects of drugs. Apart from demonstrable pathological sequale the patients vitality – the general level of health – may be lowered, and it is often possible by constitutional prescribing to raise the patient’s vitality to the extent that functional disorders and diseases with reversible pathological changes may be cured. It is sometimes also possible to help in this way to some extent even in incurable conditions.
- Acute infection
- When a patient is slow in recovering from any acute infection certain remedies, such as Sulphur, Psorinum and Carbo veg., suggest themselves, but the prescription must be selected individually. In these circumstances or when prolonged ill-health follows, the nosodes of acute infections may be invaluable. Kent and others have rightly condemned the indiscriminate use of nosodes. The place of nosodes of acute infections is fairly clear. They should be considered:
- (a) in the absence of satisfactory indications for a proved remedy and
- (b) when remedies apparently well chosen on a symptomatic basis fail to achieve adequate results.
- Constitutional Prescribing
Apart from the probable advantage of careful constitutional prescribing prior to giving the appropriate nosode, there is another reason why these nosodes should be given only after due consideration. That is, that they may work like a charm or not at all. The same applies to administration of a potency of any drug which has adversely affected a patient.
- Chronic infection
- The therapeutic field of nosodes of infections is vast and probably important, though not easy to exploit with our present limited knowledge. For example, brucellosis, with its protean manifestations, often missed because it is not considered as a diagnostic possibility, is regarded by some authorities as a widespread infection in this country. There is practically no reference to brucellosis in homoeopathic literature at all. Nosodes tend to be neglected in homoeopathic practice because of the influence of Hahnemann’s theory of chronic disease and Kent’s powerful endorsement of much of it.
- Arnica montana has been used domestically for centuries for the effects of falls and bruises, and its proving demonstrated that Arnica acts homeopathically..
- For the after-effects of head injury there are a group of remedies, Arnica, Cicuta, Hypericum, Nat. mur., Nat. sulph. and Hellebores, and these demand consideration also if there is a history of difficult birth. A child of six years of age took cold very frequently, had never thrived properly. He was markedly under weight, and had “no interest in life,” very sensitive to noise, afraid of the noise of a high wind and had other symptoms of Nat. sulph. The history of a difficult birth confirmed the choice and the administration of Nat. sulph. was followed by a rapid improvement in health, mentally and physically.
- Occasionally patients react in other ways after head injury. One child developed Nux vomica symptoms and was helped by Nux vomica. The list of such remedies is merely a record of frequent clinical associations.
- Psychic factors
- Sometimes there is a clear history of a complaint starting after grief, fear or other emotional upset. The lists of remedies clinically associated with such precipitating causes found in Kent’s Repertory and elsewhere may be valuable, giving confirmation to an individually chosen remedy. Sometimes an emotional upset may apparently occur prenatally. Staphisagria is well known for its effects when there is a strong sense of injustice. A number of remedies have this – listed in Kent’s Repertory under “Mortification” – but Staphisagria is most often needed when this is a leading symptom, in my experience.
- Hahnemann observed that Nux vomica was a useful remedy for “the evil consequences of coffee and wine drinking” and sine then Nux vomica has been extensively used for the after effects of drugs in general. Pulsatilla has been found effective in treating patients upset by iron. Nat. mur., and other remedies have been used to counteract the effects of prolonged drugging with quinine in malarious districts. Thus certain relationships have been established between constitution and the influences of drugs. As a rule constitutional treatment can deal with the after-effects of drugs once the drug has been excreted. There are also many records of drug effects being antidoted by the same drug given in potency. It is better to prescribe constitutionally first, as a potency of the drug may work dramatically or not at all. It is interesting that the same applies to the nosodes of acute infection in respect of ill health following an acute illness as already mentioned.
- It is interesting to speculate on what exactly happens in such cases when the drug which has adversely influenced a patient helps dramatically when given in potency- Is it that in these successful cases the drug is in fact one of the constitutional remedies for that individual, that it would have helped in any case whether the patient had had an overdose of it or not?
- Other factors
- A number of items may be of value in some cases. Exposure to radiation if judged to be excessive may call for a trial of X-ray 30 or 200 or Radium bromide 30 or 200 as intercurrent remedies. Illnesses beginning at puberty suggest a careful look at Pulsatilla and when ill-health starts after the menopause, Lachesis and others.
- Family history
- In making a psychosomatic homoeopathic prescription or a prescription based on the individual’s past history, the patient is regarded against a background of a theoretical norm. The same applies to “family history” and the same rule regarding any uncertain symptoms – if in doubt discard them and look for something definite. Should there be a strong history of tuberculosis or cancer in the family, the appropriate nosodes deserve consideration. Recent studies of Carcinosin suggest that it may be a useful remedy when one or more of a group of diseases are strongly represented in the family history – carcinoma, leukemia, tuberculosis and diabetes.
SOME REPERTORIAL REFERENCES OF PAST HISTORY
- General- History – Personal- Abortion of with sub rubrics
- General- History – Personal – Abscesses of recurrent
- General- History – Personal – Abuse of
- General- History – Personal – Antibiotics of use of
- General- History – Personal – Birth trauma of
- General- History – Personal – Bite of Animals
- General- History – Personal – boils of recurrent
- General- History – Personal – bronchitis of recurrent
- General- History – Personal – Chest complaints of
- General- History – Personal – Complaints of recurrent
- General- History – Personal – Cornea of recurrent inflammation of
- General- History – Personal – diarrhea of recurrent
- General- History – Personal – epitasis of recurrent
- General- History – Personal – laryngitis of recurrent
- General- History – Personal – gastro-intestinal complaints of
- General- History – Personal – Loss of fluids of
- General- History – Personal – malaria of
- General- History – Personal – measles of
- General- History – Personal – medicine of abuse of allopathic
- General- History – Personal- sexual abuse of
- Mind- Aliments from- Death of loved ones
- Mind- Aliments from- Alcoholism of
- Mind- Aliments from- betrayed from being
- Mind- Aliments from- business failure
- Mind- Aliments from- cares worries
- Mind- Aliments from- debauchery
- Mind- Aliments from- deceived from being
- Mind- Aliments from- domination
- Mind- Aliments from- fright
- Mind- Aliments from- joy excessive
Trend of adding rubrics related to past complaints are gaining momentum and we find many such are being added not only in generalities and but also in different chapter. This needs to be ascertained for being taken into totality.
Richard Hughes said “The rule Similibus can obviously be carried out only in proportion as the effects of drugs on the healthy body are ascertained.” Past History provide a component for completing the totality in a given cases. Similar remedies can, however, be chosen otherwise. There are different bases of similarity and there is no reason why different approaches to homoeopathic prescribing should not be appropriately utilized.
- Hahnemann-Organon of Medicine-6th edition, B. Jain Publishers, New Delhi.
- Hahnemann-Lesser Writing, B. Jain Publishers, New Delhi.
- Hahnemann-Chronic Diseases, B. Jain Publishers, New Delhi.
- T. Kent- Lectures on Homoeopathy Philosophy, B. Jain Publishers, New Delhi.
- Donald Foubister, The Significance of Past History of Homoeopathic Prescribing, Jain Publishers, New Delhi
Author: Dr Sanjiv Kumar Singh
Associate Professor, G.D.Memorial Homoeopathic Medical College & Hospital,
Managing Director: Research Institute of Sahni Drug Transmission & Homoeopathy