ABSTRACT
Taking case histories and carrying out physical examinations of children differs from those of adults and comes with a set of challenges. In order to maximize the success of examination, time must be spent by the physicians to gain confidence of such patients. Physician must have good communication skills and the ability to develop rapport with children as well as their families. In homoeopathic practice, it is a fact that a well taken case is half cure. Some special observations and questions during case taking will help to find out a homoeopathic similimum for the patient, some of which are focused in this article.
KEYWORDS: paediatric cases, case taking, homoeopathy.
INTRODUCTION
The skill of clinical examination is the true art of medicine and nowhere more seen than in the examination of children. Recording profiles of paediatric patients and conducting physical examinations differs from adults and pose a set of challenges. The physician needs to be flexible, tactful, intelligent, and able to tailor the examination to the individual infant/child. In order to maximize the success of examination, adequate time must be spent trying to gain their confidence(1).The symptoms are typically reported by a parent or guardian, who may not be able to accurately transmit the information from the child to the to the clinician and characterise the child’s concern. To fill in the gaps, a paediatrician must have good communication skills and the ability to develop a rapport with children as well as their families. The paediatrician must pay special attention to the growth and developmental abnormality unique to the paediatric population and be aware that specific diseases manifest differently in children than in adults(2).
In homoeopathy, recording case has two objects in view. First is the object of diagnosis not for therapeutic purpose but as a guide to the desired therapy and classify symptoms. The second and greater object in taking the case is to select the true symptoms of the patient and draw a true picture of the ills of the patient(3). In aphorism 83 of Organon of Medicine, Hahnemann clearly mentioned about the qualities of the physician required during case taking, for example, freedom from prejudice; sound senses; attention in observing and fidelity in tracing the picture of the disease(4). According to Dr Kent, the examination of the patient must be continued with due respect to the nature of the sickness and with due respect to the nature of materia medica(5). In the foot note of aphorism 90 of Organon of Medicine, Hahnemann has pointed out that the physician should observe the behaviour of the patient during case taking like whether he is morose, quarrelsome, hasty, lachrymose, anxious, despairing or sad , or hopeful, calm, etc.(4). This will help to find out the true similimum. This article covers the cautions and observations required by the attending physicians while dealing with paediatric cases, especially in homoeopathic practise.
GENERAL INSTRUCTIONS
Attitude of the physician(4,5)
- Must be soft, gentle, friendly and caring with genuine interest;
- Must be polite to the children and never get angry with them even if they are at their worst;
- Approach the child with smiling face and treat him as a child but not as a patient.
- Should not start examining the child as soon as he/she enters the clinic; rather, first try to build a good rapport with the child before examination;
- Questioning should be avoided at the very beginning of the communication. Make the children feel at their ease by asking them about their names, school names, best friends, etc;
- Avoid staring at the children because they are often scared if you intently look to their eyes;
- Should notice the interactions between the child and parents. This reveals amount of concern of the parents towards the child’s health;
- To obtain desired information, it is necessary to keep privacy and gain confidence of paediatric patients which is often overlooked as some children are often irritated with their parents, but comfortable to share their thoughts with the physicians when alone;
- Next step: now I am going to check your ears…, rather than asking the child for permission. For example: “is it ok if I check your ears?”
- Having toys in the clinic is useful for distracting children’s attention and small inexpensive gifts can be handed out to them after the visits to build rapport.
- The most important attribute of any good doctor is to be a good listener. Listen carefully to mothers and note what they say. History taking is the vital cornerstone of paediatric problem solving. More important information is often gathered from a good history than from physical examinations and laboratory investigations. The first important ground rule in history taking is: Mother is always right until proved otherwise. Mothers are, by and large, excellent observers of their off springs, who make good interpreters of their problems when sick.
In short, the physician should adopt proper techniques and higher intelligence, while dealing with paediatric cases.
CASE PROFILE (1–3,5–7)
The following data should be collected from the patients as well as their parents/guardians/ attendants.
- Presenting complaints with duration, location, sensation, modalities and concomitants (if available).
Examples: When does it occur? How long has he had it? Can you describe it? What brings it on? Does anything relieve it? How long does it last? What is its pattern and periodicity? Are there any associated symptoms? What does he do when he has it? What have you done about it? Where is the pain? Show me where it is? What is it like? What do you do when you get it?
2. History of present illness: Every complaint should be mentioned with mode of onset, causation (for example, vaccination, physical/emotional factors, etc.) up to the present state, including treatment taken for any ailment and result thereof.
3. Past history: of previous illnesses which suggest the miasmatic background
4. Prenatal history, i.e., maternal history during pregnancy;
- Did the mother have any particular illness or infection or was she taking any drugs during pregnancy?
5. Birth history
- How was the delivery: normal vaginal or caesarean, etc.? Full term?
- Birth weight? Enquire about jaundice, breathing & feeding difficulties, fits etc.
6. Postnatal history
- About vaccination/ immunisation
- Did any bad effects follow caccination? Example, cough, tonsillitis, fever, diarrhoea, etc.
- Immunisation history: What immunisations the child had? when? How many times? Which type?
7. Lactational history
- How was the baby fed? If bottle fed, which milk?
- When did weaning start? When were solid foods introduced?
- Any intolerance to a particular food?
8. Developmental history
- Gross motor status, vision and fine motor, hearing and speech, social behaviour.
- Mile stones like rolling over, crawling, walking, talking, smiling, sitting up, dentition, able to draw line, pedalling tricycle, imitating speech of others, recognising colour, etc.
- If child is precocious, then it should also to be recorded accurately.
9. Family history
- How many children are there in family? Their age, sex, etc.
- Any still births, miscarriages, or childhood deaths in family?
- Any illness(es) in siblings, parents or near relatives?
10. Treatment history: details of medicines taken; reaction if any; currently on medication or not?
11. Personal history
- What are the child’s present habits with regard to eating, sleeping, bowel movement, and micturition?
- Any unusual behaviour which the parents are worried about?
- Living conditions of the parents?
- Employment status of the parents?
12. Physical generals
Physical makeup: obese/thin, emaciated; tall/short height; dark/fair complexion
- Reaction to heat and cold;
- Desire/aversion to covering, fanning, in winter and summer?
- Bathing desires in hot/cold/luke-warm water?
- Desire/aversion to open air;
- Craving/aversion/intolerance to different foods and drinks; cold/warm foods and drinks;
- Appetite: increased/decreased/normal
- Thirst: increased/decreased/normal
- Stool: Diarrhoea/constipation; hard/soft; semi-solid/semi-liquid/watery; odour: offensive/odourless, mucous/blood present or absent; pain: present/absent; pain: before/during/after stool;
- Urine: scanty/profuse/normal; colour; smell: offensive/odourless, any particular smell; pain present (before/during/after)/absent; character of pain.
- Perspiration: profuse/scanty, cold/warm, more in which season; on which part(s) of the body; any particular smell/odourless.
- Sleep:
- Sleeps on abdomen? Sleeps like a dog?
- Changes position frequently? Sleeps with legs wide apart?
- Sleeps in knee-chest position? Sleeps with limbs drawn up?
- Boring head into pillow?
13. Mental symptoms
- If the child becomes angry easily; if so, due to any cause? How it is expressed?
- Fear of loud noises, dark room, animals, high places, strange persons, objects, being alone. In pre-school children- ghosts, monsters, darkness, sleeping alone. In school going children-school performance, results, reprimands from teachers, etc.
- Nature – shy/short tempered/obstinate/pampered/irritable/timid/daring/destructive
- Intellectual/lack of intellect
- Emotional reactions (become prominent when exposed to situations): Example- when punished by parents, reacts violently/supressed anger/indifferent/lachrymose
- Sociability: How does he get on with other children? How does the child compare with siblings or friends of the same age?
- Reaction to jesting? Envy feeling?
- Hobbies: Music/dancing/playing; activity: slow or hyperactive
- Memory: Normal/sharp/decreased; loss of memory for recent/remote things?
OBSERVATIONS IN NEW BORN
- Is the new born comfortable in mother’s lap?
- Does carrying give relief or not?
- Does she/he have habit of thumb sucking or nail biting, putting anything in mouth, etc.?
- Abnormal behavioural patterns, if any, for example, frequently washing hands or body washing/breath holding spells/temper tantrums, etc.?
CONCLUSION
It is often a herculean task to obtain the real portraits of paediatric patients unlike adults. Therefore, children the approach to their examination is different. The physician should be flexible, tactful, intelligent while dealing with them and must spend enough time to gain their confidence as well as get their real pictures. Accurate observations, many times, help the clinicians for correct diagnosis and also to find out homoeopathic simillimum. Child’s behaviour and disposition are also to be considered. History of antenatal and postnatal information always helps us for diagnosis as well as selecting the correct medicine. Homoeopathy believes in individualisation, while treating all types of cases including patients of paediatric age group. However, meticulous observations and correct history taking of the paediatric cases chiefly helps to determine the remedy.
REFERENCES
1. Michael G, William MD. Hutchinson’s Clinical Methods:An integrated Approach to Clinical Practice.24th ed. Edinburgh: Elsevier; 2018.
2. Gill D, O’Brien N. Paediatric Clinical Examinaion Made Easy. 6th ed. London: Elsevier; 2017.
3. Robert HA. The Principles and Art of Cure by Homoeopathy. 3rd ed. New Delhi: B. Jain Publishers(P) Ltd.; 2005.
4. Hahnemann S. Organon of Medicine [Dudgeon RE, trans]. 5th ed. New Delhi: B. Jain Publishers(P) Ltd.; 2018.
5. Kent JT. Lectures on Homoeopathic Philosophy. 7th ed. New Delhi: B. Jain Publishers(P) Ltd.; 2002.
6. Kumar P, Clark M. Essentials of Paediatrics. 2nd ed. Thalange N, Beach R, Booth D, Jackson L, editors. London: Elsevier; 2013.
7. Hahnemann S. The Chronic Diseases, Their Peculiar Nature and Their Homoeopathic Cure. New Delhi: B. Jain Publishers(P) Ltd.; 2005.
About Author:
Chaturbhuja Nayak
Formerly: Director General, Central Council for Research in Homoeopathy, Govt. of India, New Delhi; President, Homoeopathy University, Jaipur , Rajasthan & Principal-cum-Superintendent ,
Dr. Abhin Chandra Homoeopathic Medical College & Hospital, Bhubaneswar, Odisha, India.
Amrita Mishra
First year M.D. (Hom.), Dr. Abhin Chandra Homoeopathic Medical College & Hospital, Bhubaneswar, Odisha, India.
★Corresponding author:
Prof. Dr Chaturbhuja Nayak , DHMS (Hons.), Dip. NIH (Hons.), M.D. (Hom.)
