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
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:

1. Functional:   a physiologic disorder; a pathophysiologic disease

process without overt structural changes.
2. Mental/emotional:   a neurosis or psychosis; a predominantly
psychosomatic or somatopsychic disturbance.
3. 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:

1. 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.
2. 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.