CHAPTER 1: INTRODUCTION TO SYMPTOMATOLOGY

Chapter 1
Introduction To Symptomatology
From R. C. Schafer, DC, PhD, FICC's best-selling book:

“Symptomatology and Differential Diagnosis”
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Diagnosis and Symptomatology Diagnosis Direct vs Differential Diagnosis Symptomatology Elements in Diagnostic Logic Case Histories and Clinical Profiles Descriptors Profile StructureIntroduction to Symptomatology Interpreting Signs and Symptoms Functional and Structural Changes Visceral Lesions Multiple Signs and Symptoms Personality Changes Laboratory Workups Chiropractic Philosophy A Simplified Approach to Differential Diagnosis Steps in the Diagnostic Process Format of Chapters
Chapter 1: Introduction to Symptomatology

Diagnosis is the determination of the nature of a patient's state of health. It is the sole means by which a doctor can rationally suggest the direction of treatment or referral.

The position of the Council on Chiropractic Education (CCE) is that a doctor of chiropractic, as a member of the healing arts, is a physician concerned with the health needs of the public. He or she gives particular attention to the relationship of the structural and neurologic aspects of the body in health and disease. Serving as a portal of entry to the health-delivery system, the chiropractic physician must be well trained to diagnose, including, but not limited to, spinal analysis; to care for the human body in health and disease; and to consult with, or refer to, other health-care providers.

With respect to diagnosis, the position of the CCE is that appropriate evaluative procedures must be undertaken by the chiropractic physician prior to the initiation of patient care. There must be proper and necessary examination procedures, including recording of patient and family history, presenting complaint, subjective symptoms, objective findings, and skeletal-biomechanical and subluxation evaluation. And, when clinically necessary, such procedures as clinical laboratory tests, instrumentation reports, psychologic evaluation, roentgenographic examinations, and such other procedures should be performed as may be indicated. These findings must be correlated, and a conclusion, a diagnosis, or clinical impressions should be established.

This chapter describes the basic clinical approach used in this manual. The roles of diagnosis and symptomatology in clinical practice are defined. The goals and criteria of case histories and clinical profiles are reviewed. The gross framework for interpreting symptoms and signs is described. An overview of basic chiropractic philosophy is presented. And a simplified approach to differential diagnosis is recommended.

     Diagnosis and Symptomatology
The noun diagnosis is derived from the Greek, and it means to distinguish, discern, know, or see through. A diagnosis is any decision, conclusion, or opinion reached by the practitioner. Dorland's Medical Dictionary defines the word as the determination of the nature of a cause of a disease. Diagnosis implies the identification of a disorder by observation and investigation of its symptoms, signs, and other manifestations. Diagnosis should not be confused with nosology, which refers to the "science" of the classification of diseases.

Diagnosis

Within the health sciences, the word diagnosis is used in two separate and distinct ways. First, it is applied to that scientific knowledge which enables one to discriminate between the normal and the abnormal. The purpose of this is to determine the location and nature of disease. Second, it is applied to any conclusion or opinion reached from the examinations conducted. Thus, in the first sense, the doctor uses diagnosis and diagnostic methods in his investigation. In the second sense, the doctor arrives at a diagnosis or clinical opinion concerning the location, nature, and/or cause of the patient's trouble.

To arrive at a diagnosis is not to arrive at a fixed opinion. The purpose of diagnosis is more than
(1) to identify whenever possible the cause of a patient's health problem and

(2) to direct therapy towards rehabilitation.
Its purpose is also to assess the effect of therapy. Thus, it is a continuing process: a means to monitor therapy and verify accuracy of the original opinion. Because of this, the first diagnosis arrived at is often referred to as a working or tentative diagnosis in cases not completely clear.

The three major phases of diagnosis are symptomatology, physical diagnosis, and clinical laboratory diagnosis. Symptomatology relates to symptoms and their significance. Physical diagnosis, obviously, relates to the physical examination of the patient, and clinical laboratory diagnosis refers to the examination of the patient utilizing sophisticated clinical equipment usually requiring technical skills.

Direct vs Differential Diagnosis

The word diagnosis is also used relative to its application such as a direct or differential diagnosis. A direct diagnosis is accomplished when all symptoms, signs, and findings clearly point to one disease. A differential diagnosis is the determination of the essential characteristics between two or more similar diseases. In actual practice, a patient may present a symptomatic picture that is common to many diseases. These symptoms must be related to and compared with the case in question until all possibilities are eliminated except one and a differential diagnosis is arrived at. Thus, a differential diagnosis is the determination of which one of several diseases may be producing the symptoms by excluding all other diseases.

Disease is a by-product of the interaction of irritants, forces, and processes both within and without the patient, and all these factors have their influence on the patient's total adaptation. However, these factors are not all equal in their importance in a given patient. A differential diagnosis is necessary to qualify which are of paramount importance in any individual case.

Symptomatology

Many years ago, Pottenger wrote: "The one outstanding need of modern medicine is accurate clinical observation and interpretation.... There is no study today that offers us greater hope for the future practice of medicine than the study of the individual who has the disease and the means by which the disease expresses itself in his tissues, secretions, and excretions ...."

A symptom is a normal physiologic response to a harmful stimulus. A syndrome is any set (complex) of symptoms that occur together. Every symptom and sign has a beginning and a course of development that may be progressive or fluctuating. Symptoms and signs are products of the body that produced them. Each body creates symptoms and signs in an unique way, and each personality adapts to them in an unique way.

One symptom by itself usually means very little. It is its relationship to other symptoms that is significant. For instance, vomiting accompanied by abdominal pain in the lower right quadrant may suggest appendicitis, while vomiting with headache and failing vision could lead one to suspect something causing increased intracranial pressure.

The art of diagnosis is developed by learning to recognize characteristic symptom and sign groups and their anatomical and pathophysiologic relationships. Only in rare instances will a few symptoms lead to a clear diagnosis. Most clinical diagnoses will be comprised of a syndrome, supported by several physical signs observable to or elicited by the examiner, and correlated with laboratory and roentgenographic data interpretations.

Symptoms are either subjective or objective, or both. Subjective symptoms are those perceptible only to the patient. Examples of such sensory disturbances are pain, tenderness, fatigue, headache, nausea, vertigo, itching, tingling, and numbness. Pain and itching are pure subjective symptoms. Objective symptoms are those evident to the observer and called physical signs. Examples of such physical signs are temperature, pulse rate and rhythm, respiratory rate and character, temperature, posture, edema, gait. Faint cardiac murmurs and pulmonary rales are pure objective signs. Spinal subluxations, fixations, hypermobility, and curvature are also examples of objective symptoms. Such signs depend upon the function and structure of the part examined. They denote diseased conditions, but not particular diseases.

There are also presenting, signal, withdrawal, and pathognomonic symptoms. A presenting symptom (chief complaint) is that symptom, or group of symptoms, about which the patient complains or seeks relief. A signal symptom is a subjective experience indicative of an impending seizure such as in epilepsy or migraine. A withdrawal (abstinence) symptom is a symptom resulting from sudden withholding of a drug or abstaining from a substance or act to which a person has become addicted. A pathognomonic symptom is one found in but one disease, thus a vitally important sign. Examples of pathognomonic symptoms include the strawberry tongue of scarlatina, Koplik's spots of rubeola, and "rusty" sputum in streptococcal pneumonia.

Elements in Diagnostic Logic

A symptom can never be a diagnosis. A headache is a symptom, even if it is called cephalgia. Anything that is an effect of something such as pain, immobilization, instability, dystonia, myopia, atrophy, and so forth, cannot be a diagnosis. The cause of the effect is the diagnosis, and this is arrived at by analysis and evaluation of all semeiotic symptoms, signs, and findings.

To seek the cause of the ailment is to seek the diagnosis. Thus, to fail to arrive at a diagnosis or arrive at a wrong diagnosis is to fail to determine the cause. Since chiropractic's inception, practitioners have been directed to "look to the cause." To seek the cause is to seek the diagnosis.

Harvey emphasizes that diagnosis involves two basic procedures:
(1) the observation and recording of adequate and correct information, and

(2) the correct interpretation of the information.
Errors in diagnosis arise when either of these procedures is imperfect or the analysis is faulty (not thorough).

The collection of data is a searching process, seeking an explanation that will lead to a clinical hypothesis based on the facts at hand. The explanation must be continually verified to confirm or negate the doctor's initial hypothesis. Thus, the successive steps leading toward a correct diagnosis are:
1. Collecting the facts (data gathering) a. Clinical history d. Neurologic examination b. Physical examination e. Ancillary examinations c. Orthopedic examination f. Progress reports. 2. Analyzing the facts (data interpretation) a. Critical evaluation of data d. Selecting the disease(s) b. Listing reliable symptoms, or disorders that best fit signs, and findings in the the facts at hand order of their apparent e. Continual verification importance of the current diagnosis c. Excluding disorders that might produce similar data.
Accurate evaluation of symptoms, signs, and laboratory data requires a knowledge of the natural history of the disease process at hand as well as of the pathophysiologic manifestations that are being evaluated. This often requires "separating the chaff from the wheat kernel" by listing the facts in the order of their importance. Once this is done, each fact can be given a priority prior to analysis and the means by which each fact will be verified can be established. Those facts given high priority must be accounted for in the final diagnosis. Therefore, before the doctor can take rational therapeutic action, such action should be preceded by careful observation and description, interpretation and verification, and diagnosis and review.

      OBSERVATION AND DESCRIPTION

The first two steps are to observe and describe. Much of the purpose of the doctor's observation is to understand and appreciate the patient's background, habitus, note the degree of functional difficulties and pathologic processes evident, and grade the scope and pertinence of abnormal findings found within the interview, physical examination, and associated laboratory studies. The doctor describes when he tabulates his observations. This is a sifting of pertinent facts from irrelevant information that results in condensed, logically organized, patterns of data. A typical patient will present a number of abnormalities that will not be related to his present illness, and a decision must be made as to what is important and what is not.

      INTERPRETATION AND VERIFICATION

The next two steps are interpretation and verification. When information about the patient has been tabulated, it must be reviewed in light of the doctor's basic science knowledge and clinical experience. The doctor must weigh and differentiate the pattern of the patient's problem with the pattern of known disease processes. Once an initial possible determination is made, logical diagnostic procedures are selected, given a priority, and scheduled to verify this opinion. As the examinations and tests are conducted, their findings must be tabulated, interpreted, and judged against the particular patient and his status.

      DIAGNOSIS AND REVIEW

Diagnosis means more than applying a label to a disease process. While it means to identify disease(s) accounting for a patient's illness, it means to a greater extent to determine the nature of the patient's distress. While a label helps in identification and is necessary for various legal and communication reasons, it may not always accurately predict therapy or prognosis even if it determines the course of initial therapy. If, however, patient progress does not show the results expected, then the working diagnosis and course of treatment based upon it must be modified. New facts and deductions may lead to a new hypothesis.

The tendency to jump to conclusions based upon a few facts must be avoided. For many reasons, interpretation of history, physical, and laboratory findings may be faulty. The patient may not be perfectly open and honest during the interview. Subjective symptoms are often a mixture of emotional and physiologic factors, and physical findings can be misleading. Positive or negative laboratory tests are not always accurate. All standard diagnostic procedures are helpful; none are perfect.

     Case History and Clinical Profiles
If one had to sum up the doctor's role as diagnostician in one term, it would probably be "decision maker." Every clinical procedure or referral conducted is started because some decision had been made. The quality of the decisions made are determined essentially upon knowledge, clinical skill, personal interest, experience, practice goals, and data collection and interpretation.

The structure of the diagnostic process in the typical chiropractor's office consists of
(1) developing a patient profile,

(2) recording the history,

(3) conducting the physical examination and spinal analysis, and

(4) interpreting necessary laboratory reports and x-ray films.
These procedures may be directed either to specific problems such as low back pain, hypertension, asthma, or they may be directed in a comprehensive manner that identifies all the patient's problems even if some are not a concern to the patient at the time. Thus, the direction that these procedures will take will be determined by both patient and practice goals.

Symptoms usually appear quite early before marked physical signs of disease are evident and before laboratory data are useful in detecting malfunction. For this reason if for no other, a high-quality case history is necessary to lead the doctor to correct conclusions.

The presence or lack of a symptom may be of great interest during the case history process just as the presence or lack of a sign may be of great interest during the physical examination. Thus, both the presence of or the lack of symptoms and signs should be recorded. To record only positive symptoms and signs is to record only half the facts and may prove to be an omission of inquiry.

The value of the first interview and the patient's history cannot be overestimated. It is the point in which the doctor and patient first have contact and attempt to construct an interpersonal bond. It elicits valuable information about the person as an individual and establishes the first steps toward the later diagnosis. It designs the physical examinations that are to follow, and it makes certain signs and symptoms more significant. It provides an index to the seriousness of the illness. It indicates probable laboratory tests, and it begins to direct the role of future therapy. In the majority of instances, the physical and laboratory examinations that follow will either
(1) confirm an accurate case history or

(2) indicate case history inadequacy.

Many errors in diagnosis can be traced to errors in data collection such as
(1) failure to ask important questions,

(2) failure to obtain adequate patient response to questions,

(3) failure to adequately explore important leads, or

(4) failure to place information in proper perspective.
Some patients overemphasize symptoms while others tend to de-emphasize them, depending upon their emotional state and motivations.

An accurate and comprehensive case history of patient data must regulate and mandate diagnostic studies and aid in the interpretation of the same. McBryde and Blacklow state, "...50% of the diagnoses made are possible solely on the data obtained from a complete case history. Another 25% of the diagnoses are based on the physical examination alone. Laboratory, x-ray, and other procedures contribute 20%, with 5% of the cases nondeterminable."

Descriptors

Recorded symptoms should often be modified by certain descriptors. These are usually words, for example, that refer to:

Alleviating-exacerbating factors: relieved or aggravated by therapy, medication, exercise, rest, sitting, lying, sleeping, coughing, eating, drinking, or nothing.
Associated factors: pain, nausea, fever, chills, headache, breathlessness, dizziness, emotional tension, sweating, loss of appetite, sleeplessness, etc.
Character: sharp, burning, dull, deep, superficial, throbbing, tingling, pressure-like, cramping, squeezing, crushing, hot, cold, and sometimes color (red, blue, yellow, etc) or texture (soft, hard, thick, watery, etc).
Course: rapid, slow, stable, intermittent, fluctuating, progressing, subsiding, completely relieved.
Episode duration: seconds, minutes, hours, days, weeks, months.
Location-radiation: from anterior chest to left arm, from right upper quadrant to right scapula, from left flank to groin, from upper neck to eyes, from lower back to left calf, etc.
Number of episodes: frequent, intermittent, occasional, increasing or decreasing in frequency.
Occurrence: meal time, morning, afternoon, evening, during sleep, etc.
Onset: abrupt, gradual, or insidious.
Precipitating factors: position or postural change, environmental change, exertion, foods, alcohol, etc.
Resulting life-style changes: diet, exercize, hygienic habits, personality, sexual relations, sleep, etc.
Symptom history: recent (hours, days, weeks) or long term (months, years).
Such descriptors need not be limited to describing pain. They may be used with most common complaints. Their consistent use encourages thoroughness and helps to establish a base of data.

Profile Structure

A patient's history is usually structured to incorporate seven distinct elements that are descriptions of the patient's
(1) presenting symptom,

(2) present illness,

(3) accident history,

(4) family history,

(5) health history,

(6) personal history, and

(7) a systems review.
The interview, however, need not be conducted in this order.

The facts gained during the interview will become the basis for making a therapy decision when they are correlated with physical and laboratory findings. Of all these procedures, most diagnosticians feel that the history during the initial interview is the most important. It should never be rushed.

The interview is not complete unless you are confident that you understand:

The beginning and course that the patient's problem has followed.

Where the problem is located and its nature.

The quality and quantity of the problem.

Under what circumstances the problem is aggravated and relieved.

Associated manifestations of the problem.
      PRESENTING SYMPTOM

The presenting symptom (chief complaint) consists of a brief statement, preferably in the patient's own words, concerning his reason for seeing the doctor. It also portrays the patient's sense of priorities about his problems. The presenting symptom is the major problem for which the patient is seeking help. It is the response to such questions as, "What seems to be the matter?" or, "How can I help you?" Probing into the patient's chief complaint will frequently uncover diseases and disorders that were predestined in years past and could have been avoided or minimized if an efficient case history had been obtained at that time. The doctor's role should be as much preventive as it is therapeutic.

      PRESENT ILLNESS

A detailed description of the patient's current problems developed chronologically is called the "present illness." After the presenting symptom has been discussed, the doctor should proceed to ask, "What else has been troubling you lately?" Your goal is to encourage the patient to relate all his problems so you can arrive at a comprehensive description of the present illness. When this description is completed, you should have a list of the patient's problems --some possibly related to the chief complaint and others that are probably not. Clinical judgment will determine their priority consideration.

The quality of this judgment is determined to a great extent by how thoroughly you understand the beginning and course of the problem, where the problem is located and its radiation, the problem's quantity and quality, what circumstances aggravate or aid the problem, and what manifestations are associated. Answers to these questions should be available for each complaint.

      ACCIDENT HISTORY

A detailed accident history is vital to a complete patient history. Discuss in detail the where, when, and how each accident or severe strain occurred. Ascertain the care administered, the scope and degree of trauma, the diagnostic tests taken and the care administered. For example, many whiplash cases under allopathic care are dismissed upon the relief of pain. Joint stiffness and fixation often result because of compensatory connective tissue effects of the over-mobilization, similar to traumatic arthritis effects. Proper manipulation would prevent this: if not completely, then to a large extent.

In an automobile accident, for instance, it is important to know from which side the force came, the position of the patient at the time of impact and after. Was a seat belt or shoulder harness fastened? Did the patient's head strike anything? Was there unconsciousness? What were the immediate symptoms? What were the later manifestations? These and many more similar questions must be deeply probed.

      FAMILY HISTORY

Genetic factors are sometimes involved in diabetes, renal disease, hypertension, mental illness, heart disease, cancer, and allergies. Inquiries should be directed toward the health status of grandparents, parents, and siblings. Ages and causes of death are important information. Determine if one or more members of the family is experiencing or has experienced symptoms similar to those presented by the patient. Genetic counseling may be advisable later with presymptomatic members of the family, and reproduction risks should be discussed if it is appropriate.

      HEALTH HISTORY

To assess the patient's personal health history, inquiries should be directed toward childhood diseases, major illnesses, hospitalizations, operations, pregnancies (deliveries and abortions), allergies (air-borne, contact, medications, food), drugs, immunizations and reactions to such.

      PERSONAL HISTORY

The patient's personal history usually consists of a brief narrative about the patient's way of life:
(1) life history, including usual day's activities,
(2) education,
(3) marital status,
(4) occupational mental and physical stress,
(5) personality and temperament,
(6) hobbies and special interests,
(7) habits,
(8) religion,
(9) diet, and
(10) finances.
The purpose of this profile is for the doctor to form a mental picture of the patient's present life-style: home, work, and recreational activities to see if anything therein may be the cause of or contributing to the patient's health status and to gain insight into the impact of the patient's problems on his or her daily activities and vice versa.

      SYSTEMS REVIEW

The purpose of the systems review is
(1) to determine malfunction in areas not covered in the present illness; and

(2) serve as a check for a manifestation of the present illness that was previously overlooked or forgotten by either patient or doctor.
What is most pertinent depends upon the individual patient's chief complaint, present illness, uniqueness of the patient, and degree of suffering.

Whenever symptoms suggest involvement of a particular system or organ, questions should be directed to determine if any other possible symptoms normally associated with such a dysfunction are or have been present. The goal of the review is to assess the functional integrity of the various systems of the body.

When the case history is complete, the doctor should have a fairly good idea as to which one of three important pathophysiologic groups the patient's problems fall into:

Functional: a physiologic disorder; a pathophysiologic disease process without overt structural changes.
Mental/emotional: a neurosis or psychosis; a predominantly psychosomatic or somatopsychic disturbance.
Structural: an organic disorder, with or without signs of overt pathology.
It is often most difficult to draw the line between functional and organic illness. In functional disorders, there is undoubtedly a degree of chemical and intracellular alterations preceding gross structural (organic) manifestations. In addition, nontraumatic altered structure and its gross signs and symptoms are inevitably preceded by altered function and its more subtle symptoms.

A sign or a symptom is never an isolated phenomenon. It has multiple inter-relationships, some physiologic and some psychologic, that can be of a major or minor importance. The patient's problems can only be interpreted and a diagnosis made possible when the clinical significance of the patient's signs and symptoms are fully appreciated.

     Interpreting Signs and Symptoms
Doctors often speak, and quite loosely so, of "abnormal" signs and symptoms. Yet all signs and symptoms are the body's normal response to an abnormal situation. Poor health is the consequence of the body's inability to cope with some force of stress.

There is one basic reason for studying signs, symptoms, and, for that matter, the case history: to determine the pathophysiologic processes involved.

Memorizing the specific symptoms of specific disease entities has little clinical value unless the processes involved are understood.

Knowing "why" a certain sign or symptom is present is vital for comprehension and competent therapy. This requires a firm grasp of the basic sciences and the clinical application of academic theory.

Functional and Structural Changes

Symptoms resulting from physiologic changes can be the result of:

Altered function: eg, convulsions, tremors, arrhythmias, various visual disturbances, paresthesia, and aberrant articular movement.
Decreased function: eg, atrophy, flaccid paralysis, depression, bradycardia, constipation, numbness, dehydration, hypothermia, and articular fixation.
Increased function: eg, hypertrophy, spastic paralysis, anxiety, tachycardia, diarrhea, pain, edema, fever, and articular instability.

Symptoms of structural changes are typically the result of:

Bone and joint infection with resultant soft-tissue reactions, subperiosteal calcification, decalcification, bone destruction, and infiltration processes.
Congenital anomalies.
Deformity --witnessed as abnormal changes in angulation, displacement, or loss of continuity.
Degenerative processes.
Endocrine and metabolic imbalances.
Malignant and benign tumors.
Trauma.
Visceral Lesions

The practice of chiropractic is of course not restricted to the management of neurologic and musculoskeletal disorders. In writing of the differential diagnosis between organic and functional visceral disturbances, Pottenger stated broadly that a motor or secretory disturbance in any important organ belonging to the enteral system, unless accompanied by sensory, motor, or trophic reflexes in skeletal structures, is NOT due to inflammatory organic change in the tissues of that organ. The only exception to this rule given is in conditions where the amount of tissue involved in the organic change would be so small in extent or the irritation so mild in degree that the reflex action would involve so few neurons as not to be detected; or it might be that the stimulation would be so mild as not to be able to overcome the resistance in the nerve path and make itself evident in reflex action.

Multiple Signs and Symptoms

A doctor's diagnostic skills are fully tested whenever
(1) an acute disorder is superimposed upon a chronic or subclinical disease process,

(2) when a localized disease exhibits multiple remote manifestations,

(3) when there is the simultaneous presence of two or more unrelated diseases, and

(4) when there is a hysterical conversion reaction, which can imitate symptoms of almost any physical disease.

      MULTISYSTEMIC DISEASE

A localized disease process may give rise to constitutional or remote manifestations that direct attention away from its primary site. For example, a large number of infections, neoplastic diseases, cardiovascular diseases, connective tissue diseases, granulomatous diseases, and metabolic diseases can present multisystemic manifestations. This makes the diagnostic process most challenging. Collagen diseases frequently present multiple symptoms. Typical diseases are periarteritis nodosa and disseminated lupus erythematosus.

It is not uncommon in chiropractic practice to see joint manifestations associated with lesions in other systems. Typical examples include:

Acromegaly Leukemia Septic arthritis
Ankylosing spondylitis Pulmonary disease Sickle cell anemia
Dermatomyositis Reiter's syndrome Syphilis
Erythema nodosum Renal disease Tuberculosis
Gout Rheumatic fever Ulcerative colitis
Hemorrhagic dyscrasias Rheumatoid arthritis
Henoch's purpura Scleroderma

      PSYCHONEUROTIC DISORDERS

Hypochondriasis and anxiety states invariably present a long list of complaints. Matousek underscores that the hypochrondiac is preoccupied with body functions, and anxiety produces widespread consequences because of frequent hyperventilatory hypocapnia and epinephrine release. While it is true that multiple symptoms are typical of psychoneurotic disorders, this fact should not be used as an excuse to eliminate other functional or organic possibilities. A psychoneurotic conclusion should always be supported by competent psychiatric evaluation.

Personality Changes

Besides obvious functional and structural effects, every illness has an emotional component. Sometimes this component is slight, and sometimes it may amount to an emotional crisis. Health and well-being cannot become complete unless there is both physical and emotional recovery. Young and inexperienced physicians have a tendency to negate, minimize, and sometimes even ridicule psychologic manifestations. This is probably the result of academic over-emphasis upon objective technical data rather than upon the patient as a whole. It is also much easier to interpret laboratory data than it is to evaluate subjective responses during the diagnostic workup.

The technical and scientific aspects of health science can be learned through books and courses; however, the art of clinical practice can only be learned in the doctor-patient relationship of health "care." For this reason, the diagnostic process can never become fully computerized. To diagnose means to thoroughly understand, and one cannot fully understand unless the human elements are taken into consideration. A computer may be helpful in the accumulation and sorting of data, but it can never be programmed to interpret correctly in light of human problems.

As mentioned, diseases affect both the physical and psychic equilibrium. The nature and extent of the harm done depends upon the previous condition of the patient as well as upon the nature and duration of the disease. This thought was brought out by Pottenger who compared the two general reactions:

Disease affects the physical being by influencing the physics of the cell directly, or indirectly through changes in its own and in its environmental electrolytes which may be brought about by the vegetative nervous system and the glands of internal secretion.
The influence of disease upon psychic reaction manifests itself in both acute and chronic maladies. Sometimes acute, serious, psychic reactions follow acute diseases, which run their course in a few days. Chronic pathologic conditions, however, result in prolonged harmful stimulation of nerve cells, which produce in them a condition of fatigue and irritability that leads to a more or less general disturbance in body function. This often results in a change in the individual's reaction toward his social as well as his physical surroundings. The former results in wrong trends of thought and shows in stability of conduct. Nearly all patients who suffer from chronic disease show some abnormal degree of neurosis. No patient with a well-marked neurosis can escape a disturbance in physiologic equilibrium. Irritability on the part of nerve cells means unstable action, which has as its necessary concomitant, disturbed function; and this when long continued is prone to disturb the individual's method of thought and influence his conduct.
There is no doubt that psychic imbalance encourages a basis for disease. By altering nerve and chemical control, it produces pathologic metabolic states; it is but natural that these should lower resistance and predispose to infection.

Most symptoms are due to altered nerve and endocrine activity. The stimuli that disturb this physiologic control may be either physical or psychic in origin and the resulting action depends upon the cell and its electrolytic balance.

      BODY LANGUAGE

The term body language refers to nonverbal communication expressed in body movements, gestures, and mannerisms. Behavior of hands, fingers, arms, legs, feet, and head offer frequent signs which reflect inner feelings. Facial expressions, eye movements, voice tone and inflection, as well as standing, sitting, walking and working postures offer other signs.

Behavior is rarely rational: it is habitually emotional. We may speak wise words as the result of intelligent reasoning, but our entire being reacts to feelings. And for every thought supported by a feeling, there is a muscle change. When tonicity changes, there is always a biomechanical reaction. Primary muscle patterns are the biologic heritage of man: man's whole body records his emotional state at any given moment.

Conscious or unconscious behavior in motion is but an outward expression between verbal language and body language, between what a person's words reveal and what his subtle actions are really telling us. It is a dynamic example of the correlation between a person's inner and outer being. Emotional tension is almost always manifested as physical tension. Chain smoking and a loss in one's sense of humor are frequent signs.

Body language offers both positive and negative signposts to the careful observer. When the examiner sees negative groups of signs, it's a clue to remedy the situation if it is possible. The subject is telling the examiner something that he feels, but for some reason cannot put into words. For instance, if the examiner should say something that evokes a sign of confusion or doubt from the patient, it is the doctor's clue to offer more clarity or evidence. When the alert doctor sees positive groups of signs, this tells him that the relationship is positive and that communication is not meeting indifference or rejection.

Our entire mental and emotional equipment, temperament, personal experiences and prejudices are utilized in self-expression, influencing and directing the relationship of body parts to the whole. This equipment includes the working unit for motion --the nerve-muscle action on bones.

Our osseous structures are much more than nature's coat racks from which to hang muscles and tendons. They play an important role in our sense of control and position in our environment. How we center them determines our degree of self-possession, and they are continually being centered in our rhythm of movement. Mechanically, physiologically, and psychologically, the human body is compelled to struggle for a state of relative homeostasis.

      ORGAN LANGUAGE

In infancy, the control of the body's functions makes a lasting imprint upon the mind and becomes part of the mental processes. As we learn to control our bodies and their functions, we build up our psychic structure. Thus, the mind is not developed independently of the body. It is very definitely linked to it.

The function of the mind is to promote control of our being and its relations with the environment. When strong feelings and thoughts exist that cannot find expression in word or action, they may find expression through some organ or system. The result is a "language of the organs," which may express itself in illness if the personality is not sufficiently developed to solve problems through other channels.

According to Hodge, the organ that "speaks" is most likely the organ whose function was in the ascendancy when environmental conditions were unfavorable and produced pain (anxiety) in the mind. But constitutional predisposition, identification with an authority figure, or other factors may also determine the "choice" of organ or system in which to express.

Physical signs are frequently symbolic of neurosis. A feeling of oppression in the chest accompanied by sighing respirations in the absence of organic findings indicate that the person has a "load on his chest," which he would like to get rid of by talking about his problem. The girl who has lost her appetite (anorexia nervosa) and as a consequence has become severely undernourished is often emotionally starved just as much as she is physically starved. The common symptom of fatigue is frequently due to an emotional conflict, which uses up so much energy that little is left for other purposes.

Emotional tension of unconscious origin may express itself as muscle tension giving rise to aches and pains as sharp as those seen in acute neuralgia. According to current theory, an ache in the arm may mean that the subject would like to strike someone but is prevented from doing so by the affectation. Itching very often represents dissatisfaction with the environment that the individual takes out upon himself, martyr-like he scratches himself (shows aggression) instead of someone else. Chronic itching is often seen in the type of patient who "lets things get under his skin." Weak legs and vertigo are common physical expressions of anxiety. The digestive tract is, above all other systems, the pathway through which emotions are often expressed in human behavior. The patient with nausea, who has no evidence of organic disease, may be indicating that he cannot "stomach" a situation.

Psychosomatic disorders may be independent of or parallel with organic disease. When we add the possibility of somatopsychic disorders, the importance of a thorough physical diagnosis and spinal analysis is brought to light if our intention is to provide a health service to the whole patient.

Laboratory Workups

Some disorders can neither be seen, felt, or heard by an examiner. Nephritis, duodenal ulcer, and intervertebral disc herniation are typical examples. All that the diagnostician can do is to elicit the symptoms and signs that are the clinical effects of functional or morphological derangements. By way of roentgenography, for example, he or she may visualize some of the shadows. By certain laboratory tests, the doctor may better appreciate the abnormal function in histologic, physiologic, and biochemical terms.

      CRITIQUE OF NEED

Before any laboratory test is selected, the doctor should ask several pertinent questions:

What specific question do I want to have answered?
What is the best test available to answer this question?
Will this test cause any special risk to the patient?
What variables or attributes will be measured?
How precise or specific will the measurements be?
What probabilities can be made from a given test?
The number of ancillary procedures is almost endless. Such a critique will help to reduce the quantity and improve the quality of the information gathered. In many instances, ancillary tests are ordered to firmly confirm a working diagnosis rather than to establish a diagnosis.

      SAMPLES

The following laboratory procedures are valuable in the detection of etiologic factors when indicated by history and physical findings:
Bilateral weight balance, Objective posture and A-P and lateral distortion analysis Blood chemistry profiles Roentgenography Electrical resistance Smears and cultures (skin conductivity) Thermography Electromyography Urinalysis Hematologic profiles

Less frequently, the following procedures may be required:
Basal metabolism Hair analysis Tonometry Contourography Skin scrappings Vitamin level Electrocardiography Spirometry (serum) determinations Electroencephalography Stool analysis

In some situations where the diagnosis is unclear, referral may be necessary for the following laboratory, medical, or surgical procedures:
Allergy skin tests Endoscopy Phlebography Arteriography Esophagoscopy Psychometric tests Audiometry Exploratory surgery Spinal tap Biopsy Intravenous pyelogram Synovial fluid analysis Culdoscopy Laparoscopy Tomography Cystoscopy Myelography Ultrasound scans

The above suggestions are not to be considered inclusive.

      FALSE CONCLUSIONS

Most test results become significant only when compared to an arbitrary mean value above or below the normal mean for a large percentage of people with that disease or disorder. Unfortunately, these ranges usually overlap in healthy and unhealthy groups (the ambiguous zone). Thus, errors in interpretation can arise even when the finding or measurement is accurate.

If a doctor concludes that a patient has a disease when in fact he does not, the error is referred to as a false positive. The error is called a false negative when the opposite occurs and a diseased patient is pronounced healthy. The frequency of such errors depends on where the normal limits of the test are set. If the upper limit is set too low, there will be many false positive conclusions. If the upper limit is too high, many false negative errors will occur. For this reason, the limits of an ambiguous zone are usually set to avoid false negative errors.

     Chiropractic Principles
If we can understand basic nature, we can better comprehend its rebellion in the form of dysfunction or disease. The more we can recognize disease processes in their infancy by their subtle clues, the fewer incurable cases will result from the failure of health science to recognize them prior to advanced degeneration and pathology. We must be ever alert not to become so preoccupied with effects that we fail to recognize causes: a common failing of overspecialization.

It is a most rare acute or chronic ailment that is not representative of some generalized disturbance. A disturbance in one system reflects itself to some degree in all others, for the body is a closely integrated complex and much more than the sum of its parts. In addition, we are all unique, down to our fingerprints. The textbook description of a disease entity is usually a generalization.

Disease is not a static condition but a process that manifests itself as certain signs, symptoms, functional alterations, and structural changes. These occur as an action of the body to motor responses (essentially), both of a somatic or visceral nature within the nervous system. In turn, these motor responses must have a beginning in sensory stimulation. Such initial sensory irritations arise from our environment, are of a varied and complex nature, and their effects are dependent upon an inherent resistance of the organism at a specific given time. Disease is thus dependent upon the irritants of our environment overcoming cellular resistance and the nervous system acting as the mediating factor between. As life is a stimulus-response mechanism in its normal homeostatic functions, disease is an abnormal response to stimuli, which in turn may be beyond the capacities of the organism to adapt physiologically.

Pathologists often categorize the cause of disease into two major factors: environmental and constitutional.

The major environmental factors are physical trauma or injury; various parasitic, bacterial, fungal, viral infections, etc; harmful inanimate objects such as inert foreign bodies or chemical toxins; or nutritional abnormalities from:
(1) deficiency and/or excess in various food substances, and

(2) deficiency in a local tissue from an impaired blood supply.
The major constitutional factors are inherited genetic abnormalities and nongenetic factors that may lower a person's resistance to disease by impairing his constitutional health, particularly as a by-product of previous disease states. Thus, the chiropractic approach to disease is an attempt to determine and remove these irritations from a patient's environment and to build up resistance to disease by improving constitutional health.

These processes, however, are complicated by the nervous system, which reacts to irritations or deficiencies by establishing certain neurologic patterns of response. There may then be created within the body certain neurologic response "habits" that result in physiologic and structural alterations. These alterations can act as an intrinsic source of neurologic irritability that may persist long after the initiating stimulation has ceased. This internal source of sensory stimulation may then cause the sensorimotor responses that give rise to various symptoms, signs, functional changes, and structural alterations.

The physical changes secondarily created by these reactions, or primarily by trauma, disease, anomaly, or other factors, may act as a physical source of neuropathologic reflexes that we label a chiropractic subluxation syndrome. More specifically, this is an abnormal physical relationship between adjacent anatomical structures whose contiguous tissues are eliciting neurologic responses that may be clinically manifested in symptoms and signs, but far less than the complete disruption of a dislocation. These subluxations may exist in the static juxtaposition of related structures or anywhere within a point or portion of their biokinetic range of motion.

Subluxations are of pathologic significance because of the evoked abnormal responses and reflexes. Due to the complexity, quantity, diversity, and ramifications of reflexes arising from paravertebral soft tissues, their integrity, as mirrored by the static and dynamic functions of the vertebral column, is of primary concern. However, similar lesions can exist elsewhere in the musculoskeletal and visceral structures, which may act in a like manner and give rise to neurologic reflexes that are aberrant in nature. These too must be considered in the same context.

     A Simplified Approach to Differential Diagnosis
Because patients present symptoms, rather than a textbook description of a disease process, a method is necessary to assist the clinician through the deductive process necessary to arrive at an accurate diagnosis. The primary goal of any good analytical method should be to help the doctor quickly arrive at a rational data base from which a working diagnosis can be made. In some cases, a rapid diagnosis may avoid a life-threatening situation or halt a rapidly progressing disorder.

Hudak uses the term protocol to refer to any organized method of analyzing and dealing with a disease process or symptom complex. This definition will also serve our purposes in this manual.

Steps in the Diagnostic Process
The recommended diagnostic process is conducted in five steps.

STEP ONE: INITIAL EVALUATION
Evaluate primary symptoms (eg, functional changes, structural changes), evaluate miscellaneous symptoms, and group the symptoms into one or more basic etiologic categories. For example:

a. Functional changes (eg, pain, abnormal vital signs, bloody or non-bloody discharge, reflexes, range of motion, spasticity/flaccidity, or emotional states).

b. Structural changes (eg, atrophy, deformity, or mass).

STEP TWO: VISUALIZATION
Visualize each of the above categories (a, b) in respect to the gross anatomy, histology, physiology, and pathology involved, and correlate with the symptomatic picture. The protocols presented in this manual allow the cause(s) of each symptom to be analyzed by one or more of the basic sciences.

For example, a 32-year-old white female might present with a complaint of acute left lumbar pain. By applying his knowledge of anatomy, the doctor would visualize the lumbar vertebrae, discs, cord, intervertebral foramina contents, peripheral nerves, paravertebral soft tissues, and the area's circulatory and lymph drainage system. He would also visualize those structures that often cause reflex pain to that area such as the upper cervical spine, feet, trigger points, uterus, left ovary and tube, left kidney, ileocecal valve, and colon. Knowledge of physiology and biochemistry are especially important in analyzing any abnormal functional changes involved.

STEP THREE: DEVELOP A LIST OF PROBABLE CAUSES
Develop an initial differential list of probable causes. During the history and examination processes, certain pathophysiologic disturbances are defined by the diagnostician. These are sorted out by making an outline to approach a definitive diagnosis. This plan of action consists of an algorithm in which a decision tree is formed. The methodology is one of triangulation in which all signs of abnormality are integrated with the history involved, various examination findings, and test data to render a differential diagnosis opinion. To accomplish this, it is recommended that all symptoms be analyzed relative to 10 basic etiologic categories. The mnemonic TIN-VEND-CAT will be helpful in their recall:

The 10 Basic Etiologic Categories

T - Traumatic (extrinsic and intrinsic)

I - Inflammatory

N - Neurologic

V - Vascular

E - Endocrine and metabolic

N - Neoplastic

D - Degenerative or deficiency

C - Congenital

A - Allergic or autoimmune

T - Toxic

The first word, TIN, represents the three most common causes of conditions seen in a chiropractic office. The second word, VEND, represents the four next most common etiologies. The third word, CAT, represents the least frequent, but not rare, possible causes for the symptom.

If a patient presents a complaint of severe headaches, for example:
T - A history of trauma might suggest concussion, subdural hematoma, retinal detachment, subluxation, fracture, intervertebral disc (IVD) rupture, or other soft-tissue injury.

I - Inflammatory causes would include sinusitis, dental abscess, hepatitis, retinitis, encephalitis, meningitis, or brain abscess.

N - Some neurologic causes brought to mind would include suboccipital nerve entrapment, increased intracranial pressure, temporomandibular joint dysfunction, cervical neuritis or radiculitis, hypocalcemic neuralgia, referred pain and reflexes, and anxiety and other psychic disorders.

V -Under vascular disorders, the doctor might consider migraine, hypertension, vasospasm, or temporal periarteritis.

E - Causes such as excessive stress, fever, diabetes mellitus, ovarian dysfunction, hyperparathyroidism, pituitary adenoma, and acromegaly could be considered under possible endocrine disorders. Some metabolic disturbances would include electrolytic imbalance, acid-base imbalance, caffeine withdrawal, porphyria, hepatic precoma, and toxic states.

N - Neoplastic disorders such as nasal or sinus polyps, primary brain tumor, or metastatic carcinoma should always be considered.

D - Degenerative or deficiency causes could include cervical spondylosis, anemia, renal failure, cirrhosis, arteriosclerosis, deficiency of vitamin B435, and visual-impairment possibilities.

C - Under congenital causes, aneurysm, platybasia, basilar impression, and partial occipitalization could be listed.

A - Allergic or autoimmune disorders such as allergic rhinitis, food allergies, covert histamine reactions, or periarteritis might be considered.

T - Toxicosis can result from such possibilities as drug reactions, uremia, acidosis, alkalosis, environmental poisoning, excessive caffeine intake, vitamin A toxicity, nitrite or carbon monoxide intoxication, and the anoxia of chronic emphysema.

STEP FOUR: RULE OUT UNLIKELY SUSPICIONS
The history and findings from the physical, orthopedic, neurologic, roentgenographic examinations and ancillary procedures are then used to rule out similar conditions developed in Step 3 and establish a working diagnosis. Another systems review at this time will be highly significant because the questions asked will be directly related to the differential diagnosis process.

STEP FIVE: REASSESS AND VINDICATE THE DIAGNOSIS
Periodically reassess and vindicate the diagnosis. It may be impossible to arrive at a definitive diagnosis in some instances. Regardless, at least a list of "most likely" and "least likely" causes should be at hand until isolation of an entity or entities can be made.

These clinical protocols are not absolutes. They will undoubtedly be challenged and improved upon in time. However, at this point, it can be said that they:
(1) avoid performance that is solely memory based,
(2) help to insure thoroughness,
(3) provide a consistent data base,
(4) are convenient to implement,
(5) encourage continued learning, and
(6) facilitate self-audit of performance.

Format of Chapters

In the following chapters of this manual, each complaint will be analyzed in a curt style. Symptoms are arranged in Part II according to region and common etiologic factors. Whenever practical, each symptom will be discussed in relation to:
1. Its definition

2. The basic investigative approach

3. The symptom's etiologic picture

4. Common associated complaints and findings

5. Laboratory workup considerations

6. Differential diagnosis tips
As mentioned in the preface, signs and symptoms are the raw material of clinical practice. Without knowledge of their pathophysiologic basis, a diagnosis cannot be arrived at and thus rational therapy cannot be initiated. The format used throughout this book and the comprehensive index provided at the end of the text will provide the typical physician with a simplified method to improve his or her diagnostic skills.

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Acromegaly	Leukemia	Septic arthritis
Ankylosing spondylitis	Pulmonary disease	Sickle cell anemia
Dermatomyositis	Reiter's syndrome	Syphilis
Erythema nodosum	Renal disease	Tuberculosis
Gout	Rheumatic fever	Ulcerative colitis
Hemorrhagic dyscrasias	Rheumatoid arthritis
Henoch's purpura	Scleroderma