How to Approach Acute Cases in Practice – Clinical Experience and Approaches in Pediatric Acutes

First and foremost, I would like to re-emphasize the facts: different patients need different approaches in terms of case taking and it is easier to go first into the area where the patient is at the moment, rather than to pull him forcibly into an area where you would prefer to go. All paths lead to same goal,. The question therefore is often not which method to take, but which approach to take first.

Normally the easiest entry point is wherever we see the energy of the patient. Possible methods to enter into the patient’s case include focusing on the main complaint, simply listening to the patients talk, or inquiring into the physical characteristic, to see what is very peculiar in the complaint. Approaches can be individualistic and depending on the case, which approach to choose depends on the presentation of the case.

• OBSERVATIONS
• KEYNOTES
• STATE
• PATHOLOGY
• SYNERGY
• TOTALITY
• CONCOMITANT
• MODALITIES

 

Many  patients  in  their  acute  condition,  keep  on  talking and talking,   explaining  the  complaint  lesser  and  more of  their  anxieties. In  such  cases I will not listen to the story,  till  the  time  patient gives  me something that does not fit the logic in  the  case , which  can  be  a  definite  entry, into the case

What I have found is that if the patient mentions being “uncomfortable”  and  does  not  go  beyond  it,   that is  the  point, where you pick up the peculiar  symptoms or understand what posture the patient adopts in the illness – physically or emotionally.

I have observed in acute cases that we must treat the patient’s out of proportion reactions to the illness, then utilize the objective symptoms, which are free of interpretation. I  pay  a  lot  of  importance  to  observation  and  look  for  one  peculiar symptom,   combining  that with the general symptoms  which  I  believe  are key to the  prescription.

Generals are like thermals and cravings. Moreover, if the pathology is acute and talking to you, we can use this in the prescription. For example if the body is showing inflammation, discharges, redness, or different temperatures, this is a sign of the body expressing itself. These are active pathologies and we can use them for the prescription.

However, if the diseases are in dormant pathology, we can use the individual characteristics of the patient. As a homoeopath, we must understand the process and expression of pathology, what happened, and how it happened,  its  pace, and  correlate  with  the  sphere  of  action  of  the   remedy.

In Acute Cases and conditions, it is important to understand that case-taking starts right from the time the patient enters the clinic and does not stop until they exit the clinic.

Requisites for prescribing for an acute case:

• Ardent observation skills
• Diagnosis and detailed history taking of the symptoms: Pathology, Prognosis, and  the  course

of  the  illness,  or  the  pattern  of  the   same

• Cause of disease
• State of the patient (objectively and subjectively)
• Physical examination,  it  is   very  important, to  touch  and  see  for   local  symptoms, like

local  warmth, coldness,  perspiration etc

• Remedy choice and  comparative  study and auxiliary modes of management

Each area of interest will be studied thoroughly in the subsequent text.

Ardent observation skills

First and foremost, homoeopaths must give utmost importance to Observation. Keen observatory skills are the key to success in acute prescriptions. Observation is the action or process of observing something or someone carefully or in order to gain information. Observation is also the ability to notice things, especially significant details – by using four out of the five senses (sight, smell, sound, and touch).

The subsequent list is an example of what to observe as soon as the patient enters the clinic:

• Appearance – what does the patient look like (gender, race, pallor, posture, build, height and weight)?
• Facial expressions – many recognized emotions are shown through facial expressions (fear, anger, surprise, contempt, disgust, happiness, boredom, confusion, embarrassment, sadness, etc.). There are also facial expressions that are not necessarily connected to an emotion, like a frown, glare, grimace, pout, smile, smirk, eye contact or wink.
• Gait – Different gaits are characterized by differences in limb movement patterns, overall velocity, forces, kinetic and potential energy cycles. An Antalgic Gait is a painful gait so a limp is adopted to avoid pain on weight bearing structures. An Ataxic Gait is an unsteady, uncoordinated walk, a wide base of support is seen. Normally this gait is due to cerebellar disease. A Festinating Gait is where short, accelerating steps are used to move forward, often seen in people with Parkinson’s disease. A Four Point Gait is utilized by crutch users, first on crutch, then the opposite leg followed by the other crutch and then the other leg. A Hemiplegic Gait involves flexion of the hip because of inability to clear the toes from the floor at the ankle and circumduction at the hip. A Spastic Gait is a way of walking in which the legs are held close together and move in a stiff manner. This gait is often due to central nervous system injuries.
• Behavior – is the patient passive or aggressive, assertive or submissive, verbal or non-verbal, introverted or extroverted, etc.

Additional areas where zealous observation is essential:

• Conversation with the attendant/reception
• Reaction to surroundings

 

Diagnosis and detailed history taking of the symptoms:

Pathology, Prognosis and Diagnosis

After keenly observing, the diagnosis is made from a detailed history taking of the patient’s symptoms. The diagnosis is critical to taking an acute case.

When considering the diagnosis, it is very important to address the underlying pathology and organ or side affiliation. This can also help to a large extent when it comes time to prescribe the remedy.

Prognosis of the case can be made on the basis of diagnosis.

It is also advised to request the patient to conduct certain investigations to ascertain the diagnosis & prognosis of the case.

Cause of Disease

The cause of the acute disease must be ascertained. The following are suggestions for the cause of disease:

• Physical trauma
• Some bacteria or virus
• Food
• Water
• Some change in weather
• Exposure to temperature change
• Humidity
• Mental stress, grief, anxiety, fear, etc.

 

State of the patient (objectively and subjectively)

After observing and ascertaining the diagnosis and cause of disease, the state of the patient (the changes seen in the patient physically and mentally since being unwell) is examined. It is important to note that there can be both subjective as well as objective changes displayed by the patient in an acute state.

Objective Symptoms include:

• Activity (torpor/ dull/ playful/ hyperactive)
• Discoloration of any part during the episode
• Partial heat/ partial coldness/ partial sweat
• Position of amelioration (lying/ sitting/ carrying/ rocking in particular position)
• Moaning
• Reaction to conversation(prefers/ avoids/ nods/ snaps)

 

Subjective Symptoms include:

• Thirst in quantity & frequency
• Chilly/ hot
• Coverings (prefers / avoids / wrapping up)
• Modalities – aggravating and ameliorating
• Concomitants with the chief complaint
• Delirium
• Lachrymation
• Irritable/ mild
• Reaction to the surrounding persons (prefers / avoids)
• Reaction towards his duty (in school/ work/ home/ family/ kids)

 

Physical examination

Following investigation of the changes in the state, a physical examination is performed where carefully examine/touch the patient to detect changes of various body markers. A general examination is performed as well as a systemic examination. During these clinical examinations, the following markers are inspected:

• Any eruptions or discolorations over the body parts
• Partial temperature changes in all parts – heat or cold
• Perspiration over the body parts

 

ROLE OF PATHOLOGY, AND USE IN ACUTE PRESCRIPTION

 

Rubrics  for  pathological  generals  are  very  easily  found  in  Phatak’s  Repertory.

Examples  are:

• ‘Calculi, formation  of’
• ‘Neuralgia’
• ‘Haemorrhage’
• ‘Numbness’
• ‘Venosity’
• ‘Collapse’
• ‘Convulsions’
• ‘Cancer’
• ‘Paralysis’

 

Remedy choice and auxiliary modes of management

Once all of the previous steps are thoroughly completed, then  after  repertorization  and, studying  the  sphere  of  action  and  verifying its  action  on  the  pathology, the  REMEDY  is selected

In select cases, follow-ups occur on the same day in the evening or on the next day. Depending on the severity of the illness, follow-ups can be conducted after two to three days, or even after a few hours.

Auxiliary management like dietary improvements, fomentations and exercise are advised to aid in the recovery of the patient.

Clinical Experiences and Approaches in Pediatric Acutes

In pediatric acute cases, what you observe is the most important thing. Right from the time the child enters, in fact, even before the child enters, observe him or her.

Also, see what is observed by others and evaluate behavior and history of the child given by the parents.

We should  look for  something that  is  very  peculiar  in  the  child  when  he  is   not  well,  and then  study  the physical generals  and  concomitants and  the  state

Concomitants  are  very   important  in  coming  to  a  simillimum,  along  with  the  objective  symptoms  and  observations

ROLE  OF  INVESTIGATION:

What will help us are investigations – DO  NOT  HESITATE  TO  INVESTIGATE  the  case  when  in  doubt, and  always  it  is  advisable to  investigate  the  patient. It  is  also  helpful  in  knowing  the prognosis  and this will  help  in  prescribing also.

Other important history includes the EXACT onset, EVOLUTION and PROGRESSION of disease.

We have to decide if the disease is single, multi-systemic, organs and the system, acute, sub acute, chronic, or an acute manifestation of chronic disease?

PEDIATRIC CASES:

My golden rule in treating pediatric acutes is that the observations of the parents are what is most important, not their perceptions of the child!

Crying is also an important aspect of the child. There are many types of crying – there can be a hunger cry, which starts with little sobs followed by vigorous crying with no tears. There can be a painful cry, where there is a loud shriek followed by a pause and then vigorous crying. Here, there are always tears. Lastly there is the attention-seeking cry, where the child’s crying consists of small, whining tones with no tears. We have to differentiate the crying of the child.

Furthermore, there is a difference between crying, weeping and shrieking as well. Crying is when the child is demanding or requiring attention or action. Weeping is when the child sheds many tears as an expression of emotion. Shrieking is a shrill shriek, or frantic cry.

Some examples of crying and the corresponding homoeopathic medicine:

• Soft pitiful cry: Pulsatilla
• Irritable cry: Calcarea, Chamomilla, Ip., Sepia
• Sobs a lot: Chamomilla, Cuprum, Helleborus, Hyoscyamus, Ignatia, Lycopodium, Opium, Stramonium
• Whines and whimpers incessantly: Belladonna, Borx., Bryonia, Cina., Chamomilla, Cuprum, Nux-v., Rheum., Stramonium
• Continuous crying (or cyclical vomiting of children) = Cadmium sulph.

The commonest remedies in practice include Chamomilla, Cina, Pulsatilla, and Ignatia. Let us see some case examples along with differential diagnoses.

 

Case One

Case Summary:

This is a case of a child who came to me in a collapsed state. He had difficulty breathing and appeared to be drowsy with half open eyes. He had severe bronchitis with fever. On observation, I saw that this child had a red face.

His mother described it like a state of intoxication. When he wakes up he goes into dullness immediately and just wants to lie down. Unfortunately, the child would not get sleep because he was disturbed by the breathlessness and fever. He always wanted his mother and father beside him. In his fever, he wanted to be covered and did not want the air conditioning or fan. He would sip water occasionally but overall had no thirst. When I tried asking him questions, he would simply nod and answer yes or no. He appeared to be a very mild child.

In this case, the look of the child was the most important. He was lying down as soon as he came into the clinic. He was in a state of torpor, dullness and drowsiness. Torpor by definition is a state of physical or mental inactivity; lethargy; numbness; sluggishness.

Rubrics:

1. Dullness, heat during
2. Concomitants, face red
3. Fevers, covers, warmth agg.
4. Thirst, little, sips
5. Torpor
6. Delirium during fever
7. Desires company
8. Mildness
9. Answers  in  nods
10. Partial heat of upper extremities (touch the child, if heat in the upper and feet is cold)

 

Remedy: Pulsatilla, 200

Follow-up after the remedy: The child slept peacefully for 1.5 days, and when he woke up he had no fever.

Common Mental Symptoms of Pulsatilla seen in practice:

1. Answers, nods by
2. Carried, desire to be slowly
3. Weeping answering questions
4. Answers monosyllables
5. Clinging children of
6. Lamenting fever during
7. Torpor
8. Mildness

 

Common Physical Generals of Pulsatilla seen in practice:

1. Changing paroxysm, no two paroxysms alike
2. Perspiration uncovered parts on
3. Cough sit up must
4. Fever thirst without
5. Lachrymation fever during
6. Sweat unilateral, one sided, left
7. Feet uncover must
8. Numbness pains from
9. Blandness  of  discharges

 

Case 2

Case Summary:

This is a case of a child who had high fever which all began after he had a cold drink. He was dull, in a torpor state, was sleeping and lying down all the time. Even if there was a loud noise, the child didn’t react or move at all. The only thing that aggravated him was the draft of the fan.

He did not have any thirst, and would be aggravated if his mother put a blanket on him. When I asked him questions, he simply did not answer me.

Normally, this child is hyperactive, however in this fever, he could not even hold himself up. On a regular basis, the child is playful, attention seeking, and mischievous. He plays pranks on everyone, and his school calls at least once per day.

Rubrics:

1. Draft of air, agg
2. Lie down, inclination to
3. Dullness, fever during
4. Fever, covers, warmth agg.
5. Thirstless, general fever, during
6. Talk, indisposed to
7. Magnetized, mesmerism amel.

 

Remedy: Ignatia, 200

 

Follow-up after the remedy: After the remedy, the child’s fever improved remarkably – his temperature went down and his energy levels improved. He was playing and doing mischief the very next day.

Common Mental Symptoms of Ignatia seen in practice:

1. Irritability contradiction from slightest
2. Starting, startled frequently
3. Torpor
4. Gestures, makes stamps the feet sleep, during
5. Playful
6. When Ignatia is over fever, they love to go and play

Common Mental Symptoms of Ignatia seen in practice:

1. Fever, covers warmth aggravates
2. Thirst, chill during
3. Anterior part of body warm
4. Traumatic fever (after some sort of emotional trauma or any kind of hurt)

 

Differential Diagnosis

IGNATIA vs. PULSATILLA

• Ignatia: anterior part of body warm, traumatic fever, heat with coldness of single parts
• Pulsatilla: warmth is unbearable, upper part of body warm, pathological fever

 

Case Three

Case Summary:

This is a case of a female child who had a fever, was cranky and had a flowing nose. She was irritable and was kicking in her fever. She would shriek in her sleep during her fever and kick off the covers. Whenever someone touched her, she would get very angry and try to kick them. Her eyes were constantly watering in her fever, as was her nose. The discharge was very watery. Her mother described her during the fever as very dull and would not even want to watch television. Even in her fever, the child was very diligent and wanted to go to school.

During the day, she would like to be in her mother’s lap. She would refuse food when it was offered, and because of this, her stools were not being passed properly. If she wasn’t on her mother’s lap being rocked, she would become very irritable. In her anger, she would push her mother away and would not let her console.

The mother showed that in order to soothe the child, she would have to take her in the lap and go on rocking her. On observation, I saw the child had her thumb constantly in her mouth.

Rubrics:

1. Lachrymation, fever during
2. Dullness, fever during
3. Sucking the thumb
4. Anger approach of a person on
5. Anger consoled when
6. Aversion to being approached
7. Irritability, children in, must be carried

 

Remedy: Chamomilla, 200

Follow-up after the remedy: As soon as the child took the remedy, she passed stool and her fever subsided after 2 days. She was no longer irritable or angry.

Common Mental Symptoms of Chamomilla seen in practice:

1. Lachrymation, fever during
2. Dullness, fever during
3. Sucking the thumb
4. Ailments from contradiction
5. Ailments from scorned and being scorned
6. Anger approach of a person on
7. Anger bend backwards
8. Anger consoled when
9. Anger spoken to when
10. Aversion to being approached
11. Rapid motion  amel
12. Carried being, does not amel.
13. Disturbed averse to being
14. Irritability, children in, must be carried
15. Intolerance, spoken to of being
16. Intolerance, interruption of

 

Case Four

Case Summary:

This is a case of a young child who came to my clinic with fever. The child was constantly crying, a continuous, whiney cry.

When I tried to approach to examine her, she kicked me. She did not even want me to come near her. The only person who was able to touch her was her mother and that too, only if the mother carried her over the shoulder and rocked her very fast. Usually the child did not like to be touched or carried.

Her mother stated that during the fever the child had a cold sweat. She did not want water.

Rubrics:

1. Aversion to being approached
2. Carried desires to be, dislikes to be handled
3. Carried, desire over shoulder
4. Touched, aversion of being caressed
5. Rocking fast ameliorates
6. Carried being, does not amel.
7. Perspiration, cold, fever during

 

Remedy: Cina, 200

Follow-up after the remedy: After the remedy the child’s crying stopped and her fever reduced after just 1 hour. She came back to my clinic the next day where I noticed a huge change in her. She was not aggressive and did not try to kick me when I approached her, and her thirst increased.

 

Differential Diagnosis

Cina vs. Chamomilla

Both of these remedies are very common in pediatric acute cases, and come from the same family Compositae, where the main theme is of INJURY.

Cina

Chamomilla

Touched, aversion of being caressed Rocking fast ameliorates Reacts by showing aversion to be touched Aversion to mothers milk Aversion approached of being Aversion, handled being Cries are intermittent Carried being, does not amel. Cold sweat Continuous, whiney cry and carrying over the shoulder ameliorates, there is no reaction to the touch of certain persons (Chamomilla child will kick you if you touch them) Carried desires to be, dislikes to be handled Carried, desire over shoulder

Ailments from contradiction Ailments from scorn Anger, approach on Stiff and bends backwards when angry Carrying fast amel. Reacts by violence—shrieking, kicking One cheek red, other pale during fever Violent motion ameliorates Intolerance, being spoken to Intolerance, interruption from Cry is continuous and violent Irritability, children in, must be carried Hot sweat Warmth amel.

 

CASE FIVE

CASE SUMMARY:

She is old lady with complaint of burning urination, with backache.

The pain started in the back and then radiated downwards, more on right side .

She complained of passing urine drop by drop and pain at the urethra while passing urine.

Rubrics taken:

• PAIN, BURNING, URINATION, AFTER
• Pain meatus; urine after
• Urination dribbling by drops

 

Remedy given: Sarsaparilla 30 – 2 doses & SOS

Follow up:  After taking the first dose she felt the pain at the meatus and at the back reduced and burning urination completely disappeared after repeating the second dose.

CASE SIX

 

CASE SUMMARY:

This patient came to me with eruptions on his abdomen and back which was diagnosed as erysipelas since a week. There was no itching only redness. The patient did not have any modalities and causative factor.

So following rubrics were taken:

• Eruptions red
• Eruptions itching without
• Erysipelas

 

Remedy given: Cicuta 30 – 2 doses

Follow up: The eruptions & redness reduced in a day’s time after 2 dose of Cicuta.