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Case records in general practice
British Homteopathic Journal January 1993, Vol. 82, pp. 16-21
Case records in general practice NOEL J PRATT, MRCS, LRCP, FFHOM Abstract The author regularly collected histories of patients receiving homeeopathic treatment, over a 30-year period, using a standardized case record. The case record is described. Analysis of 1,500 such records yields useful data on patients, prescribing patterns and rate of improvement. KEYWORDS: Case record; General practice; Prescribing; Potency; Rate of improvement
On 15 March, 19481 began working in general practice with Dr Aubrey Marriott in Norwich. The practice had begun about 1840 as a charitable Homeeopathic Dispensary founded by a Miss Harriett Copeman. So the practice was well known for using homeeopathic remedies. We did, of course, use conventional treatment when necessary. I began using a few remedies while my knowledge grew, and soon was using them in about 10% of patients, much the same numbers as for analgesics and antibiotics. For 3 years I kept a record of all the patients who received homeeopathic medicines, but found that method was unsatisfactory. So I devised a printed case record sheet, so that details could be recorded in proper order, taken from the notes made at the time of consultations. Thus I had the advantage of putting the data in good order and ready for quick and easy reference. I found I was prescribing hom~eopathically for about 20 patients each week and had not enough time to record them all, so made a habit of recording 1 case each weekend when the patients reported good results with adequate follow-up. So I collected an average of 50 cases each year, making a total of 1,500 by the time I retired. The case sheet is printed on 16 gram paper, measuring 16 by 10 inches before folding to make 4 pages. Reports and letters can be attached (Fig. 1).
Patient's name, age, sex and occupation The diagnosis or main symptom The remedy which was effective and the potency used Previous treatments Investigations and specialist opinions Duration of the illness Time of improvement Time of cure Follow up
Page 2: Aetiology Symptoms in order of appearance Dosage of the remedy, with dates Response to the remedy Aggravation, if any Progress notes Disability before treatment Residual disability if any Significant events in personal and family history Physical type and modalities. Page 3: Particulars and modalities based on the arrangement of Kent's Repertory. This page can also be used for letters and reports. Page 4: Summary of the case, indicating the reasons for choosing the remedy. Sometimes this space can be used for a repertorizing table, preferably typed. Possible criticisms of the case record, with answers to them. Significant spontaneous comments by the patient, or relatives or friends, and sometimes by other doctors.
Page 1: Number of case Doctor's name 16
Volume 82, Number 1, January 1993
17
HOMo=OPATHIC T R E A T M E N T
History and progress of the case
DOCTOR'SNAME
AETIOLOGY SYMPTOMS in order of their appearance,with dates
PATIENT'SNAME AGE OCCUPATION
DOSAGE of the remedy, with potencies and dates
DIAGNOSIS or mainsymptom
RESULTS OF TREATMENT, including first reactions, and aggravations if any
REMEDYwhichwaseffective andthe potencyused
PROGRESS NOTES
PREVIOUSTREATMENTS andtheirresults
DISABILITY before treatment RESIDUAL DISABILITY, if any
INVESTIGATIONSand SPECIALISTOPINIONS EFFECTRATIO or CURERATIO
THEDISEASEHADEXISTEDFOR: IMPROVEMENTBEGANIN: CUREWASCOMPLETEWITHIN:
LENGTHOFFOLLOW-UP and conditionwhenlastseen
The case record sheet (page 1) Particulars and Modalities
Mind Head Eyes Ears Nose Face Mouth Throat Appetite Stomach Abdomen Stool Urinary Genital Heart Lungs Neck Back Limbs Joints Skin Fever Sleep
PHYSICAL TYPE. General reactions to heat and cold, etc.
The case record sheet (page 2) SUMMARY OF THE CASE, indicating the reasons for prescribing the remedy which was effective.
POSSIBLE CRITICISMS of the case, and answers thereto.
SIGNIFICANT REMARKS of patient and/or relations, indicating effectiveness of remedy.
The case record sheet (page 3)
Figure 1.
days days days
SIGNIFICANT EVENTSin personal and family history
The case record sheet (page 4)
18
British Homteopathic Journal TABLE 1. Age distribution (1,500 patients) Age distribution
%
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79
8 6 15 18 10 18 14 9
I should of course mention computers and computerized records. I am aware of their advantages. But by the time they became available for general practice, I was firmly habituated to paper records and decided not to spend time and money (and brains) on converting my records, totalling then about 1,000. Analyses of the case records At the end of each year I made alphabetical indexes of patients, diagnoses, remedies used, potencies and dosage and information from the other sections of the case sheet. Age and sex
It is clear that homceopathy can benefit people of all ages, from infancy to senility. The preTABLE 2. NO. o f cases (%) homoeopathic medicines Medicine
No. of cases
%
Rhus tox. Pulsatilla Arnica Sulphur
88 85 40 38 38 37 36 35 33 33 33 32 32 31 30 30 29 26 24 24
6 6 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
Bryonia Arsenicum album
Ipecacuanha Nux vomica Phosphorus Magnesium phos. Silicea Spongia Calcium carb Sepia Antimonium tart Ruta Hypericum Ledum Hepar sulph. Natrum mur.
Total Fig, Z
Rhus toxicodendron ftos et foL
responding to 20
756
19
Volume 82, Number 1, January 1993
TABLE 3. Potencies (1,500 prescriptions) Potencies
%
lx 3x 6x 12x 30c 200c 1M 10M
2 55 19 2 17 4 2 >1
cise age is significant in many cases, in relation to m e n o p a u s a l problems, and diseases of later years. See Table 1. Occupation
Is often of significance when choosing the remedy, because it can be an aetiological factor, physically, socially and psychologically. Diagnosis or m a i n s y m p t o m
The diagnosis was usually obvious, but sometimes it was necessary to confirm it by investigations. 17% of patients n e e d e d some investigation, X-ray o r b l o o d test o r other. Previous conventional treatment
57% of all patients had taken some conventional treatment without satisfactory response, and 15 % had taken other homceopathic remedies without success. O f those, 8% had taken a r e m e d y on m y advice without success, but r e s p o n d e d well after taking a second r e m e d y prescribed by me. Prescribing
The total number of successful remedies in this series is 151, of which 72 were of botanical origin, 45 of mineral origin, 8 o f animal origin, 12 nosodes and, 14 isopathic remedies. 50% of all patients were cured by 20 remedies (see TABLE 4. Time to improvement and disease duration/ improvement ratio (duration~time to improvement)
Time to improve (days)
%
Ratio
%
<1 1-2 3 4 5-6 >6
37 9 15 10 9 19
< 10 10-20 21-200 >100
46 21 33 8 Fig. 3. PulsatiUapratensis pl tota.
20
British Hom~eopathic Journal
Table 2). The potencies used are summarized in Table 3. The number of doses taken before improvement varied greatly, depending on the remedy and the potency and the nature of the illness. 9% of patients took only 1 dose before they had begun to improve, and had been advised to take no more than necessary (see Table 4).
Rate of improvement and follow-up A factor c o m m o n to all cases is time; the duration of the illness, the time in which improvement began, and the time in which cure was achieved. I believe that H a h n e m a n n said (though I admit I cannot find it in any of my books) he would not promise to cure anyone in less than one tenth of the time the illness had lasted. But there is no doubt that he did achieve quick results, and we can do the same. The ratio is a convenient way of showing the speed of response. The rate of response in this collection of case records is shown in Table 4. Calculation of the duration of the average case is difficult, but it seems reasonable to state that the average in this series is ill for 3 weeks, and improved or cured in 2 or 3 days. The desirable length of follow-up is variable. When relapse or recurrence is not expected, as in the case of bruises, it is not necessary. If the trouble is seasonal, as with hay fever, follow-up for one or more seasons is desirable. In other cases when the patient changes address and the case notes are passed on, it is possible to record subsequent attendances for other troubles, with no mention of the illness which was successfully treated.
Aetiology and history
Fig. 3.
Arnica montana pl tota.
One of the advantages of hom~eopathy is that the root causes can be clues to the choice of the remedy, and treatment of the cause or causes is more likely to succeed than treatment of the symptoms and signs alone. So the personal history and the family history are often helpful in deciding on the best remedy. The degree of disability before and after treatment is worth expressing separately; for example, the need for bed rest, the disturbances of sleep, the limitation of activity, including inability to go to work, and other indications of disability are worth recording. A n d the disability, if any, after treatment is all the more significant. Particulars and modalities can be recorded on page 3, based on the order in Kent's Reper-
Volume 82, Number 1, January 1993
tory. At other times I find this page useful for attaching letters and results of investigations. And quite often there are articles or reports or letters in the medical press concerning the disease, usually recommending modern conventional treatment with synthetic compounds which have their occasional side effects.
Summary The summary of the case on page 4 is not always needed, but this space can be used for explaining why the remedy was chosen. Sometimes it is useful to record a repertorizing table; about 6 remedies and 6 prescribing features can be fitted in here. Possible criticisms, and answers. It is a good discipline to use this space to imagine what comments other doctors might make, and how to answer them. At other times one has to
Address for correspondence Dr N. J. Pratt 8 Bluebell Crescent Norwich NR4 7LE
21 admit faults or omissions in the case record, and to resolve to do better in future. Spontaneous comments by the patient or a relative or a friend--not direct answers to any question one asks--can often confirm the improvement or cure achieved. Such comments are recorded in 15% of all case records. Many of these comments express surprise, and sometimes the consultants make such comments.
Conclusion Each case record can be completed in about 15 minutes, and the time is well spent. The annual indexes enable quick reference. Having the evidence in this standardized form saves a lot of time; however good the clinical notes made at the times of consultation, having the evidence in the same order is a great advantage.
Case records in general practice NOEL J PRATT, MRCS, LRCP, FFHOM Abstract The author regularly collected histories of patients receiving homeeopathic treatment, over a 30-year period, using a standardized case record. The case record is described. Analysis of 1,500 such records yields useful data on patients, prescribing patterns and rate of improvement. KEYWORDS: Case record; General practice; Prescribing; Potency; Rate of improvement
On 15 March, 19481 began working in general practice with Dr Aubrey Marriott in Norwich. The practice had begun about 1840 as a charitable Homeeopathic Dispensary founded by a Miss Harriett Copeman. So the practice was well known for using homeeopathic remedies. We did, of course, use conventional treatment when necessary. I began using a few remedies while my knowledge grew, and soon was using them in about 10% of patients, much the same numbers as for analgesics and antibiotics. For 3 years I kept a record of all the patients who received homeeopathic medicines, but found that method was unsatisfactory. So I devised a printed case record sheet, so that details could be recorded in proper order, taken from the notes made at the time of consultations. Thus I had the advantage of putting the data in good order and ready for quick and easy reference. I found I was prescribing hom~eopathically for about 20 patients each week and had not enough time to record them all, so made a habit of recording 1 case each weekend when the patients reported good results with adequate follow-up. So I collected an average of 50 cases each year, making a total of 1,500 by the time I retired. The case sheet is printed on 16 gram paper, measuring 16 by 10 inches before folding to make 4 pages. Reports and letters can be attached (Fig. 1).
Patient's name, age, sex and occupation The diagnosis or main symptom The remedy which was effective and the potency used Previous treatments Investigations and specialist opinions Duration of the illness Time of improvement Time of cure Follow up
Page 2: Aetiology Symptoms in order of appearance Dosage of the remedy, with dates Response to the remedy Aggravation, if any Progress notes Disability before treatment Residual disability if any Significant events in personal and family history Physical type and modalities. Page 3: Particulars and modalities based on the arrangement of Kent's Repertory. This page can also be used for letters and reports. Page 4: Summary of the case, indicating the reasons for choosing the remedy. Sometimes this space can be used for a repertorizing table, preferably typed. Possible criticisms of the case record, with answers to them. Significant spontaneous comments by the patient, or relatives or friends, and sometimes by other doctors.
Page 1: Number of case Doctor's name 16
Volume 82, Number 1, January 1993
17
HOMo=OPATHIC T R E A T M E N T
History and progress of the case
DOCTOR'SNAME
AETIOLOGY SYMPTOMS in order of their appearance,with dates
PATIENT'SNAME AGE OCCUPATION
DOSAGE of the remedy, with potencies and dates
DIAGNOSIS or mainsymptom
RESULTS OF TREATMENT, including first reactions, and aggravations if any
REMEDYwhichwaseffective andthe potencyused
PROGRESS NOTES
PREVIOUSTREATMENTS andtheirresults
DISABILITY before treatment RESIDUAL DISABILITY, if any
INVESTIGATIONSand SPECIALISTOPINIONS EFFECTRATIO or CURERATIO
THEDISEASEHADEXISTEDFOR: IMPROVEMENTBEGANIN: CUREWASCOMPLETEWITHIN:
LENGTHOFFOLLOW-UP and conditionwhenlastseen
The case record sheet (page 1) Particulars and Modalities
Mind Head Eyes Ears Nose Face Mouth Throat Appetite Stomach Abdomen Stool Urinary Genital Heart Lungs Neck Back Limbs Joints Skin Fever Sleep
PHYSICAL TYPE. General reactions to heat and cold, etc.
The case record sheet (page 2) SUMMARY OF THE CASE, indicating the reasons for prescribing the remedy which was effective.
POSSIBLE CRITICISMS of the case, and answers thereto.
SIGNIFICANT REMARKS of patient and/or relations, indicating effectiveness of remedy.
The case record sheet (page 3)
Figure 1.
days days days
SIGNIFICANT EVENTSin personal and family history
The case record sheet (page 4)
18
British Homteopathic Journal TABLE 1. Age distribution (1,500 patients) Age distribution
%
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79
8 6 15 18 10 18 14 9
I should of course mention computers and computerized records. I am aware of their advantages. But by the time they became available for general practice, I was firmly habituated to paper records and decided not to spend time and money (and brains) on converting my records, totalling then about 1,000. Analyses of the case records At the end of each year I made alphabetical indexes of patients, diagnoses, remedies used, potencies and dosage and information from the other sections of the case sheet. Age and sex
It is clear that homceopathy can benefit people of all ages, from infancy to senility. The preTABLE 2. NO. o f cases (%) homoeopathic medicines Medicine
No. of cases
%
Rhus tox. Pulsatilla Arnica Sulphur
88 85 40 38 38 37 36 35 33 33 33 32 32 31 30 30 29 26 24 24
6 6 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
Bryonia Arsenicum album
Ipecacuanha Nux vomica Phosphorus Magnesium phos. Silicea Spongia Calcium carb Sepia Antimonium tart Ruta Hypericum Ledum Hepar sulph. Natrum mur.
Total Fig, Z
Rhus toxicodendron ftos et foL
responding to 20
756
19
Volume 82, Number 1, January 1993
TABLE 3. Potencies (1,500 prescriptions) Potencies
%
lx 3x 6x 12x 30c 200c 1M 10M
2 55 19 2 17 4 2 >1
cise age is significant in many cases, in relation to m e n o p a u s a l problems, and diseases of later years. See Table 1. Occupation
Is often of significance when choosing the remedy, because it can be an aetiological factor, physically, socially and psychologically. Diagnosis or m a i n s y m p t o m
The diagnosis was usually obvious, but sometimes it was necessary to confirm it by investigations. 17% of patients n e e d e d some investigation, X-ray o r b l o o d test o r other. Previous conventional treatment
57% of all patients had taken some conventional treatment without satisfactory response, and 15 % had taken other homceopathic remedies without success. O f those, 8% had taken a r e m e d y on m y advice without success, but r e s p o n d e d well after taking a second r e m e d y prescribed by me. Prescribing
The total number of successful remedies in this series is 151, of which 72 were of botanical origin, 45 of mineral origin, 8 o f animal origin, 12 nosodes and, 14 isopathic remedies. 50% of all patients were cured by 20 remedies (see TABLE 4. Time to improvement and disease duration/ improvement ratio (duration~time to improvement)
Time to improve (days)
%
Ratio
%
<1 1-2 3 4 5-6 >6
37 9 15 10 9 19
< 10 10-20 21-200 >100
46 21 33 8 Fig. 3. PulsatiUapratensis pl tota.
20
British Hom~eopathic Journal
Table 2). The potencies used are summarized in Table 3. The number of doses taken before improvement varied greatly, depending on the remedy and the potency and the nature of the illness. 9% of patients took only 1 dose before they had begun to improve, and had been advised to take no more than necessary (see Table 4).
Rate of improvement and follow-up A factor c o m m o n to all cases is time; the duration of the illness, the time in which improvement began, and the time in which cure was achieved. I believe that H a h n e m a n n said (though I admit I cannot find it in any of my books) he would not promise to cure anyone in less than one tenth of the time the illness had lasted. But there is no doubt that he did achieve quick results, and we can do the same. The ratio is a convenient way of showing the speed of response. The rate of response in this collection of case records is shown in Table 4. Calculation of the duration of the average case is difficult, but it seems reasonable to state that the average in this series is ill for 3 weeks, and improved or cured in 2 or 3 days. The desirable length of follow-up is variable. When relapse or recurrence is not expected, as in the case of bruises, it is not necessary. If the trouble is seasonal, as with hay fever, follow-up for one or more seasons is desirable. In other cases when the patient changes address and the case notes are passed on, it is possible to record subsequent attendances for other troubles, with no mention of the illness which was successfully treated.
Aetiology and history
Fig. 3.
Arnica montana pl tota.
One of the advantages of hom~eopathy is that the root causes can be clues to the choice of the remedy, and treatment of the cause or causes is more likely to succeed than treatment of the symptoms and signs alone. So the personal history and the family history are often helpful in deciding on the best remedy. The degree of disability before and after treatment is worth expressing separately; for example, the need for bed rest, the disturbances of sleep, the limitation of activity, including inability to go to work, and other indications of disability are worth recording. A n d the disability, if any, after treatment is all the more significant. Particulars and modalities can be recorded on page 3, based on the order in Kent's Reper-
Volume 82, Number 1, January 1993
tory. At other times I find this page useful for attaching letters and results of investigations. And quite often there are articles or reports or letters in the medical press concerning the disease, usually recommending modern conventional treatment with synthetic compounds which have their occasional side effects.
Summary The summary of the case on page 4 is not always needed, but this space can be used for explaining why the remedy was chosen. Sometimes it is useful to record a repertorizing table; about 6 remedies and 6 prescribing features can be fitted in here. Possible criticisms, and answers. It is a good discipline to use this space to imagine what comments other doctors might make, and how to answer them. At other times one has to
Address for correspondence Dr N. J. Pratt 8 Bluebell Crescent Norwich NR4 7LE
21 admit faults or omissions in the case record, and to resolve to do better in future. Spontaneous comments by the patient or a relative or a friend--not direct answers to any question one asks--can often confirm the improvement or cure achieved. Such comments are recorded in 15% of all case records. Many of these comments express surprise, and sometimes the consultants make such comments.
Conclusion Each case record can be completed in about 15 minutes, and the time is well spent. The annual indexes enable quick reference. Having the evidence in this standardized form saves a lot of time; however good the clinical notes made at the times of consultation, having the evidence in the same order is a great advantage.