Data should be	accurate
	complete
	comprehensive
	interpreted appropriately
	corroborated by supporting evidence
	objective
	systematic
Methods should be	ethically sound
	reliable
	safe
	sensitive
	specific
	valid

Figure 3.1 The CAM assessment process

Health history

Implementing measures that build client rapport before and during the clinical consultation are critical to developing client trust, improving communication and enhancing the accuracy of acquired information.⁵ This is particularly important when completing a health history because subjective data often dominate this stage of assessment. It is probable that the quality of clinical assessments will be improved if clinicians become more consciously aware of the many factors that improve client rapport (see Table 2.1) and, more importantly, attempt to address these elements throughout the consultation.

Once measures have been put in place to build rapport, the clinician can begin to explore the client’s health history. During the initial stages of the interview, the practitioner will need to obtain sufficient information about the history of the presenting condition, which includes establishing what the client’s primary problem is and, from that, developing a more comprehensive understanding of the complaint. To fulfil these requirements, the clinician will need to acquire information about the location, quality, severity, onset, radiation, duration and frequency of the symptoms, otherwise known as the where, what and when of the complaint. The identification of concomitant symptoms, as well as factors that aggravate and ameliorate the symptom, including previous and existing treatments, foods, body position, activity, environmental conditions, temperature and emotions, will further improve the description of the presenting complaint and enable the practitioner to narrow down the causes of the condition. The following example illustrates this point.

Asking a clinician to speculate on the aetiology of a disease when the history of a presenting complaint is described as mild (severity), dull ache (quality) to the left lower abdominal quadrant (location) would be difficult and inappropriate. On the other hand, if the history added that the discomfort had been present for the past 3 months (onset), occurred intermittently every day (frequency) for approximately 1–2 hours at a time (duration), was non-radiating (radiation), improved by defecation (ameliorating factors), worsened by stress (aggravating factors) and was accompanied by bloating and flatus (concomitant symptoms), then a clinician may be able to consider possible hypotheses, such as irritable bowel syndrome. This description of the presenting complaint is summarised in Table 3.2.

Table 3.2 Core components of the presenting complaint description (ReLOAD FACQS)

Re	Radiation
L	Location
O	Onset
A	Aggravating factors
D	Duration
F	Frequency
A	Ameliorating factors
C	Concomitant symptoms
Q	Quality
S	Severity

Once the presenting condition has been adequately described the clinician can start to explore other factors that may contribute to the chief complaint, the client’s state of health and wellbeing, and the overall plan of care. These determinants can be separated into medical, lifestyle and socioeconomic factors. With reference to the medical determinants, these include family history of illness, allergies and sensitivities to foods, medications and environmental agents, over-the-counter and prescribed medications, complementary medicines and supplements, current and previous medical conditions or illnesses, and history of surgical or investigational procedures (see Table 3.3). For paediatric clients, it is important to also consider immunisation, birth, breastfeeding, growth and development history.

Table 3.3 Medical components of the health history (FAMMS)

F	Family history
A	Allergies and sensitivities
M	Medications
M	Medical conditions
S	Surgical and investigational procedures

Another important component of the health history is the client’s lifestyle history. A lifestyle history includes details about diet and fluid intake (including quality and quantity of consumed goods), illicit drug use (including type, route and frequency of use), smoking status (including strength and quantity), frequency and duration of exercise, alcohol use (including type, quantity and frequency), quality and duration of sleep, and entertainment and recreation choices (see Table 3.4).

Table 3.4 Lifestyle components of the health history (DISEASE)

D	Diet and fluid intake
I	Illicit drug use
S	Smoking status
E	Exercise frequency and duration
A	Alcohol use
S	Sleep quality and duration
E	Entertainment or recreation choices

The final part of the health history, socioeconomic background, is a particularly important component as many of the factors within this category are likely to affect a client’s capacity to understand and/or comply with treatment. This category includes information about the client’s family environment (including living arrangements, proximity of family, family dynamics), occupation and employment status, religion and cultural background, level of social support from family, friends and/or external agencies, level of educational attainment (including primary, secondary and tertiary level education), and residential and/or work environment (see Table 3.5). For paediatric clients, information also should be obtained about childcare arrangements and school performance.

Table 3.5 Socioeconomic components of the health history (FORSEE)

F	Family environment
O	Occupation and employment status
R	Religion and cultural background
S	Social support
E	Education
E	Environment (work and residential)

In an attempt to quantify the severity and/or impact of the presenting condition, some practitioners choose to use one of a number of clinical assessment tools, such as pain, depression, anxiety, stress and irritable bowel syndrome scales. Although such tools may be useful in providing clear, concise and measurable data about the presenting problem, which may help in the evaluation of client care, the validity and reliability of many evaluation tools are not well established. If the accuracy of a tool can be determined and the data are found to be reasonably consistent, then that assessment instrument may have a place in the CAM assessment process. Examples of tools that can be used in the assessment of conditions pertinent to each body system are outlined in the second half of this chapter.

Physical examination

A complete and comprehensive health history should provide the clinician with a detailed description of the client’s presenting condition and enable the practitioner to formulate a number of assumptions about the aetiology of the complaint. To determine which, if any, of these hypotheses are likely to become probable diagnoses, the clinician will need to test the assumptions by acquiring additional data. The source of such data can be derived from the physical examination (for a more detailed discussion of assumption or hypothesis processing, see chapter 4).

The physical examination is pivotal in corroborating findings from the more subjective health history, partly by adding much-needed objective data to the clinical assessment. For the examination to be accurate and reliable it needs to be systematic and all-inclusive. Using a system-based approach in conjunction with the inspection, olfaction, palpation, percussion and auscultation (IOPPA) strategy, enables a practitioner to fulfil these requirements.

The physical examination generally involves some degree of physical contact between the practitioner and client, so it is critical that the clinician establishes some level of rapport and trust with the client (see chapter 2) and has at least obtained verbal consent from the client prior to commencing the examination. Appropriate hand washing, infection control measures, privacy, client conversation, instrument use, draping, level of client contact and exposure are also important measures for reducing a client’s risk of physical or psychological harm. Because inappropriate physical contact and professional misconduct are major causes of complaint against CAM practitioners,⁶^–⁸ these strategies may also serve to protect clinicians from unnecessary professional and legal action. To further protect the client and practitioner from immediate and enduring harm, it is important that clinicians also recognise their professional boundaries and the limits to their scope of practice, and, where appropriate, refer clients to relevant health professionals for further assessment. For paediatric clients, it is important that a parent or guardian is present whenever possible.

Once these factors have been taken into consideration, a practitioner can commence the physical examination. The first part of this assessment, which begins from the time the practitioner makes visual contact with the client, is inspection. This visual assessment of the client incorporates a general and a specific component. The general inspection examines the client’s broad state of health by observing features such as posture, gait, affect, body language, physical guarding and functional capacity, which can alert the clinician to possible causes of the presenting condition as well as related comorbidities. Specific inspection focuses on the presenting complaint and associated body systems, and requires the clinician to make observations about pertinent structural and functional manifestations (including normal and atypical signs), such as a flat or distended abdomen and pink or pale skin colour.

An important element of the physical examination often dismissed in the literature is olfaction, in particular, the detection of pathognomonic odours. Apart from enabling clinicians to develop a better understanding of the presenting complaint, smell helps to identify health concerns that are neither reported nor detectable by sight, sound or touch. The presence of urine odour, for example, may indicate a client is suffering from a urinary tract infection or is having difficulty self-managing care, whereas halitosis may be a sign of dental, neurological, respiratory or gastro-oesophageal disease.

The tactile component of the physical examination, known as palpation, uses deep and light touch, where relevant, to acquire information about the size, depth, texture, temperature, mobility, firmness and tenderness of the presenting condition.⁹ Apart from corroborating observed data, palpation adds necessary detail about the condition of the underlying structures, including muscles, bones, organs and blood vessels. The tactile examination of pulses, masses, lesions and areas of localised pain are some examples of where this technique maybe applied. Palpation also provides supporting evidence for pathological processes, such as inflammation, infection and carcinogenesis. A good case in point is erythema. The presence of localised erythema to the lower limb, for instance, says very little about the aetiology of the condition, but when combined with palpable heat and tenderness, suspicions of inflammation and/or infection may be confirmed.

Complementing palpation is percussion, an examination technique that uses touch (i.e. tapping the area of interest) and sound, specifically, vibration, to define the density of the underlying structure, in particular, whether the structure is gas, fluid or solid.¹⁰ This information can help a clinician distinguish between certain pathologies without relying on invasive or costly diagnostic tests in the early stages of assessment. A particularly important place for percussion is in the early detection of pneumonia, pneumothorax, internal bleeding and organomegaly. With reference to respiratory disease, percussion can be especially helpful in differentiating between generally less fatal conditions such as lobar pneumonia (manifested by percussive dullness), and life-threatening emergencies such as pneumothorax (manifested by hyper-resonance).

The final component of the physical examination is auscultation. Auscultation uses sound to detect changes in physiological function, such as blood flow (i.e. bruits, blood pressure, cardiac murmurs), bowel motility and respiratory function (i.e. breath sounds). While auscultation is most frequently assessed using a stethoscope, the value of ultrasound and the naked ear should not be dismissed. The naked ear is useful for detecting a number of minor and potentially serious complaints, such as crepitus, audible wheeze and borborygmi, whereas ultrasound can be used to identify changes not detectable by the human ear, including fetal heart sounds and peripheral blood flow.

The data collected from a comprehensive health history and physical examination can be particularly helpful in informing the CAM practitioner about possible diagnoses, as well as the need for referral. The following example illustrates this point further. A brief clinical assessment that identifies the presence of cough and chest discomfort may mislead a practitioner into believing that a client has asthma or respiratory tract infection. A more detailed assessment that identifies the additional presence of haemoptysis, hoarseness, weight loss, dyspnoea, digital clubbing and supraclavicular lymphadenopathy, may direct a practitioner to a more probable diagnosis of lung cancer, resulting in prompt referral to an allopathic medical practitioner and the avoidance of unnecessary delays in treatment. Other clinical manifestations that should alert a clinician to the possibility of more serious pathology, and the need for prompt referral to an appropriate practitioner, are bleeding (such as haemoptysis, melaena and haematuria), escalating pain (including central chest pain, cephalgia and abdominal pain), altered levels of consciousness, seizures, unresolving masses, rapid weight loss and petechiae.

Diagnostics

The final aspect of the clinical assessment is the diagnostics phase. Depending on the practitioner’s level of expertise, this stage of assessment may require clinicians to request, perform and/or interpret findings from a range of pathology, radiology, functional, invasive and miscellaneous tests. Even though the use of such tests can be justified where there are inadequate data from the health history or physical examination to support or refute possible hypotheses, or when the outcomes of treatment need to be monitored, issues relating to access, cost, comfort, competency and convenience may be significant obstacles to ordering these investigations. Effective interdisciplinary communication, as well as appropriate referrals to pertinent health professionals, may be necessary to execute this stage of assessment.

Each type of diagnostic test is capable of addressing important gaps in the clinical assessment and of adding valuable objective data to the pool of clinical information. Laboratory investigations of blood, urine, semen, hair, wound and sputum specimens, for instance, can provide critical information about the functional status of the client (and in some cases the possible cause of the clinical picture), including data about hepatic, renal, endocrine and haematopoietic function. The thyroid function test (TFT) is a good case in point. The clinical manifestation of low libido, weight gain and depression, for instance, may be indicative of hypothyroidism. Without performing a TFT, however, it would be difficult to determine whether the client has abnormal levels of circulating thyroid hormone (and therefore hypothyroidism), and whether the condition is attributable to thyroid disease or pituitary gland dysfunction.

Functional tests also serve to explore the functionality of specific tissues, organs or systems, including the musculoskeletal, digestive, endocrine and immunological systems. These investigations generally fall into two broad categories:

1. comprehensive pathology profiles (e.g. cardiovascular profile), and

2. detailed physiological assessments (e.g. functional skin integrity testing).

Radiological tests enable a practitioner to visualise structural and functional aspects of the presenting complaint, such as bone and tissue integrity, tissue content and fluid dynamics. Medical images are created using different sources of energy, including electromagnetic radiation (i.e. computed tomography), ultrasound, and magnetic and radiofrequency energy (i.e. magnetic resonance imaging), and are enhanced with the use of contrast media (i.e. barium enema) and radionuclide (i.e. scintigraphy).

Investigations not typically performed by CAM practitioners, but for which clinicians may need to interpret findings or refer clients on, are invasive procedures. These investigations, often used in conjunction with pathology tests, provide important information about the structure, function and/or pathology of the presenting complaint, although when compared with other diagnostic methods, most invasive tests pose a greater risk of harm to the client, including an increased risk of pain, infection and haemorrhage.

The other category of diagnostic investigation, which is commonly used by CAM practitioners, is the miscellaneous tests. Despite the long history of use of these tests within CAM, particularly methods such as iridology, kinesiology, Vega testing and pulse diagnosis, there is insufficient clinical evidence to support their use. This is not to say that these methods are ineffective or should be dismissed in clinical practice, only that further research is needed to evaluate the validity and reliability of these procedures. Miscellaneous tests are not confined to CAM diagnostics: this category also captures investigations that do not nest within the other four diagnostic categories, including electrodiagnostics and sleep studies. Examples of tests that fall into the five diagnostic categories are listed in Table 3.6.

Table 3.6 Examples of diagnostic tests that may be requested, performed or interpreted in CAM practice

Pathology tests	Carbohydrate breath test
	Complete blood examination (CBE)
	Culture and sensitivity testing (C&S)
	Glycated haemoglobin (HbA1c)
	Lipid studies
	Liver function test (LFT)
	Nutrient levels (iron studies, hair mineral analysis)
	Oral glucose tolerance test (OGTT)
	Semen analysis
	Thyroid function test (TFT)
	Urinalysis (UA)
Functional tests	Adrenal hormone profile
	Bone metabolism assessment
	Comprehensive detoxification profile (CDP)
	Comprehensive digestive stool analysis (CDSA)
	Intestinal permeability (IP) test
	Pulmonary function test (PFT)
	Urodynamic studies
Radiological tests	Computed tomography scan (CT)
	Contrast studies
	Magnetic resonance imaging (MRI)
	Mammography
	Positron emission tomography (PET)
	Radiograph/X-ray
	Ultrasound (US)
Invasive tests	Allergy skin testing (prick-puncture test)
	Arthroscopy
	Biopsy
	Colonoscopy
	Endoscopy
	Laparoscopy
	Lumbar puncture (LP)
Miscellaneous tests	Electrodiagnostics (electrocardiograph)
	Iridology
	Plethysmography
	Pulse diagnosis
	Quantitative sensory testing (QST)
	Sleep studies

To this point, the structure, approach and rationale for the CAM assessment process have been presented, albeit from a general perspective, but as well as understanding the theoretical foundation of the process, a practitioner also needs to consider its application. In the section that follows, the CAM assessment process is applied to each major body system. It is important to note that this section will outline only pertinent assessment methods and investigations for each system. For a comprehensive discussion of examination techniques, particularly for special populations such as pregnant and paediatric clients, refer to a specialist text on physical assessment.

Several of the techniques and diagnostic tests listed in this section may be considered outside the scope of CAM practice, at least for some practitioners. Readers therefore need to be aware of the limitations of their practice when interpreting this information, as well as the skills or tests that are pertinent to their field of practice, the assessment techniques that may best be completed by another health professional and how these methods may or may not fit within the philosophy or context of their discipline. CAM practitioners should also ensure that they keep abreast of the emerging literature on evidence-based diagnostics to make certain that all aspects of their care are evidence-based and not just the interventions they prescribe.

Cardiovascular system assessment

The cardiovascular system consists of the heart and blood vessels, including arteries, veins and capillaries. The key role of this system is to transport blood (including nutrients, heat, oxygen, hormones and cellular components) throughout the body. Any abnormalities in cardiovascular structure or function are likely to compromise the system’s ability to deliver or eliminate vital components to and from cells, which will lead to the manifestation of adverse symptoms.

These points should be taken into account when conducting a comprehensive assessment of the cardiovascular system. An outline of the regions pertinent to cardiovascular system assessment is illustrated in Figure 3.2.

Figure 3.2 Cardiovascular assessment cue card

Health history

History of presenting condition

Identify the client’s primary problem and establish the location, onset, duration, frequency, quality and severity of the sign or symptom, the presence of radiating symptoms (e.g. chest pain radiating down the left arm or up the neck may indicate myocardial ischaemia), any aggravating or ameliorating factors (such as walking, stress, rest or leg elevation) and any concomitant symptoms (including shortness of breath, fatigue, chest pain, palpitations, claudication, paresthesias and syncope).

Medical history

Lifestyle history

Identify any factors that may increase the client’s risk of CVD, such as obesity, tobacco use (including number and strength of cigarettes inhaled in a day), alcohol consumption (including number of standard drinks and type of alcoholic beverage consumed in a day), illicit drug use (including type, route and quantity of drug used per day), diet and fluid intake (such as sodium, omega 3 fatty acids, saturated fat, fibre, fruit and vegetable consumption), quality and duration of sleep (e.g. broken sleep, sleep apnoea) and frequency and duration of exercise.¹¹

Socioeconomic background

Determine whether there are any socioeconomic determinants that may increase the client’s risk of CVD, affect their understanding of CVD or affect the management of the disease, such as family environment (i.e. marital status, number and ages of children), occupation and employment status (i.e. day or nightshift, full or part time, number of jobs), religion, ethnicity, race or cultural background (i.e. whether the client follows strict dietary practices or is placed at increased risk of developing CVD as a result of their culture, race or ethnic background), level of social support (i.e. whether the client lives alone and whether the client receives assistance from community services), level of educational attainment (i.e. primary, secondary and/or tertiary education) and residential and/or work environment (i.e. whether the client resides near an industry or arterial road).

Physical examination

Inspection

Observe for any signs of impaired cardiovascular function, such as xanthomata (hard, yellow masses that are pathognomonic of familial hypercholesterolaemia),¹⁰ digital clubbing (an abnormal enlargement of the terminal phalanges that may be a sign of chronic hypoxia), splinter haemorrhages of the nail bed (present in infective endocarditis¹²), dyspnoea, pallor or cyanosis (may be observed in hypoxia, anaemia, vasoconstriction or vascular occlusion), Lichstein’s sign (oblique, bilateral earlobe crease observed in people over 50 years of age with significant coronary heart disease),¹² dependent oedema (may be indicative of chronic venous insufficiency or right-sided heart failure), leg ulceration (may be indicative of peripheral vascular disease) and lower leg varicose veins and ochre pigmentation (both signs suggest the presence of chronic venous insufficiency). The presence of chest scars (from sternotomy or pacemaker insertion) and/or deformities (such as pectus excavatum or pectus carinatum) may also draw attention to the possibility of cardiovascular defects.

Olfaction

There are no pertinent olfactory signs known to be indicative of CVD.

Palpation

Examine major pulses of the neck (carotid), chest (cardiac apex), upper limbs (brachial, radial, ulnar) and lower extremities (femoral, popliteal, posterior tibial, dorsalis pedis) and note the rate, rhythm and amplitude of each pulse, as well as the presence of any thrills or palpable vibratory sensations (thrills are indicative of turbulent blood flow). Assess the peripheries for temperature (cool hands and feet may be indicative of cardiac failure or peripheral vascular disease) and pitting oedema (may indicate the presence of chronic venous insufficiency or right-sided heart failure). In terms of cardiac function, identify the position and diameter of the point of maximum impulse (PMI) (a laterally displaced or enlarged PMI is suggestive of cardiomegaly)¹⁰ and the presence of thrills or increased pulse intensity over the aortic area (may suggest the presence of aortic dilatation), pulmonic area (may be indicative of pulmonary artery dilatation), mitral area (may be indicative of mitral stenosis or regurgitation) and tricuspid area (may be a sign of tricuspid stenosis or regurgitation).

Percussion

Use percussion to estimate cardiac size in order to detect the presence of cardiomegaly or to assess left ventricular mass.

Auscultation

Using a stethoscope, assess the intensity, duration, timing and pitch of heart sounds, the presence of murmurs (abnormal sounds in the cardiac cycle that are indicative of turbulent blood flow through a defective heart valve), bruits (an abnormally harsh sound suggestive of turbulent blood flow through an artery) and pericardial friction rubs (a sign of pericarditis). Auscultation is also used to measure blood pressure by noting the onset and disappearance of Korotkoff sounds.

Additional signs

Clinical data not derived from the abovementioned physical examination that can provide important information about the aetiology of a presenting condition, as well as the general health and nutritional status of the client, can be derived from assessing core body temperature, weight, height, body mass index (BMI), waist circumference and skinfold thickness.

Clinical assessment tools

Examples of instruments that may be used to evaluate the severity or effect of cardiovascular complaints, or the effect of treatment on these disorders, are outlined as follows.

Aberdeen varicose vein questionnaire (AVVQ)

Measures health-related quality of life in clients with varicose veins.

Canadian cardiovascular scale

Classifies angina according to its level of effect on physical activity. Classifications range from no angina with ordinary physical activity (class I), to angina with any physical activity and/or rest (class IV).

Claudication scale (CLAU-S)

Evaluates quality of life in clients with peripheral arterial occlusive disease and intermittent claudication.

Framingham coronary heart disease (CHD) prediction score

Assigns weights to major cardiovascular risk factors, including age, gender, blood pressure, total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C) and smoking status to predict an individual’s risk of developing atherosclerosis and coronary heart disease over a 10-year period.

MacNew heart disease health-related quality of life questionnaire

Assesses the effect of coronary heart disease and its treatment on physical, emotional and social functioning, and on activities of daily living.

New York Heart Association (NYHA) grading of heart failure

Assesses the severity of chronic heart failure (CHF) according to the level of physical activity needed to manifest symptoms, ranging from class I (ordinary physical activity does not cause symptoms) to class IV (symptoms of CHF manifest at rest).

Newcastle stroke-specific quality of life measure (NEWSQOL)

Assesses quality of life in people who have suffered from stroke.

Venous clinical severity score (VCSS)

Measures the severity of nine hallmark signs of venous disease and the need for compression therapy.

Diagnostics

Pathology tests

Apolipoprotein-B:Apolipoprotein-A₁ ratio

Apolipoproteins are the major protein component of lipoproteins, with apolipoprotein-B a major component of LDL and apolipoprotein-A1 a key component of HDL. Apo-B:Apo-A₁ is an independent and significant predictor of CVD, in particular, fatal and non-fatal myocardial infarction.¹³

Asymmetric dimethylarginine (ADMA)

ADMA is a by-product of protein methylation. Elevated levels of ADMA are associated with smooth muscle cell proliferation and platelet aggregation. ADMA is also an endogenous inhibitor of nitrous oxide; elevated levels are linked to endothelial dysfunction and small vessel disease.¹⁴

C-reactive protein (CRP)

CRP is a marker of inflammatory activity, which is implicated in the development and complications of atherosclerosis.¹⁵ CRP is independently related to future cardiovascular events.¹⁵

Cardiac enzymes/proteins

These are released from the myocardium during injury, such as in myocardial infarction. Because many of these enzymes or proteins are also present in skeletal tissue, it is recommended that cardiac-specific enzymes or proteins be ordered, including cardiac-specific troponin T and I, and the isoenzyme creatine phosphokinase-MB.¹⁶

Complete blood examination (CBE)

A CBE provides important information about the cellular elements of the blood, including haemoglobin, haematocrit, the number, volume, haemoglobin concentration and width of erythrocytes, white blood cell count, and the number and volume of platelets. As a cardiovascular screening tool the CBE may assist in the diagnosis of vascular or haematological pathologies, such as anaemia, infection, dehydration and blood loss.

Hair, urine, serum and blood nutrient levels

These tests may be indicated when presenting clinical manifestations are suggestive of nutrient deficiency or toxicity, when the presenting condition is likely to be caused by nutrient deficiency or toxicity or when the condition is likely to contribute to the development of nutrient deficiency or toxicity. Nutrient tests that are particularly relevant to cardiovascular assessment are hair mineral analysis, serum vitamin B₁₂, serum magnesium, serum coenzyme Q10, serum zinc, red blood cell folate and iron studies.

Homocysteine (Hcy)

Hcy is an amino acid derived from methionine. Even though Hcy plays an important role in protein synthesis, elevated levels are associated with smooth muscle cell proliferation, platelet aggregation and impaired endothelial derived nitric oxide induced vasodilatation, all of which promote atherosclerosis.^17,¹⁸

Radiology tests

Angiography/venography

This is an invasive radiological procedure in which a blood vessel is injected with contrast media and a series of X-ray images taken. By assessing blood flow dynamics and blood vessel defects, this procedure can support suspicions of aneurysm, vessel stenosis or occlusion, and vascular malformation.¹⁶

Computed tomography (CT)

CT uses multiple X-ray beams to produce cross-sectional images of the head, chest, abdomen and pelvis to provide information about cardiovascular structure. CT imaging is particularly useful for identifying aneurysms, vessel occlusion or stenosis (with angiography), arteriovenous malformations, haematomas and haemorrhage.²⁰

Doppler/ultrasound

This test uses sound waves to assess blood flow velocity and direction, and blood flow disturbances of major blood vessels, including the carotid arteries and the arteries and veins of the extremities. It is a procedure that is useful for detecting aneurysms, vessel occlusion or stenosis, deep vein thrombosis, Raynaud’s disease, chronic venous insufficiency and varicose veins.¹⁸

Echocardiography

Echocardiography uses ultrasonic waves to evaluate cardiac structure and function, including information about heart size, position, walls, valves and chambers, the pericardium and masses. This procedure can help in the diagnosis of valvular regurgitation or stenosis, thrombus formation, endocarditis, myxoma, septal or congenital heart defects, cardiomyopathy and ventricular hypertrophy.¹⁸

Magnetic resonance imaging (MRI)

MRI uses magnetic and radiofrequency energy to produce images of the heart and vasculature, including information on structure and function. MRI is particularly useful for detecting aneurysms, congenital heart defects, myocardial infarction/ischaemia, pericardial changes, vascular malformations and arterial occlusive disease, and for determining cardiac chamber and ventricular function.¹⁸

Positron emission tomography (PET)

PET provides anatomical and functional information about the heart. Following the administration of an inhaled or intravenous radionuclide, areas of radionuclide accumulation, which reflect the level of cellular metabolic activity, are tracked by CT imaging and positron detectors. A reduction in positron emission, and thus cardiac metabolism, can occur in conditions such as myocardial infarction or scarring.¹⁶ Increased cellular metabolism may be a sign of carcinoma. Other abnormal states that may be detected by PET include heart chamber disorders and ventricular enlargement.¹⁸

X-rays or radiographs

X-rays use electromagnetic radiation to produce images of the heart (providing information about size, shape and location), pericardium (particularly the presence of inflammation or effusion), large blood vessels (such as the aorta) and, in conjunction with angiography, smaller blood vessels. Without contrast media, X-rays are limited to detecting cardiac enlargement, pericarditis, pericardial effusion and large vessel dilatation or stenosis.²⁰

Functional tests

Comprehensive cardiovascular profile

This profile identifies a number of lipid-independent risk factors that are related to cardiovascular disease, such as Hcy, CRP and fibrinogen.

Invasive tests

Transoesophageal echocardiography (TOE)

TOE assesses the size, position, chambers, valves and movements of the heart, as well as the condition of proximal blood vessels. This procedure is useful for detecting coronary artery disease, congenital heart defects, aneurysms, valve and septal defects, thrombi and congestive cardiac failure.¹⁸

Miscellaneous tests

Arterial/venous plethysmography

This procedure measures volume changes in the blood vessels of the upper and lower extremities to determine the presence of occlusive disease such as venous thrombosis, arterial embolisation and Raynaud’s disease.¹⁸

Electrocardiograph (ECG)

An ECG measures the electrical activity of the heart. The reading can be used to detect cardiac arrhythmias, myocardial ischaemia, electrolyte imbalances, conduction defects, pericarditis, cor pulmonale and ventricular hypertrophy.¹⁶

Exercise stress test

An exercise stress test assesses the response of the heart and the vessels of the lower limb to physical stress. The results can be used to identify the presence of intermittent claudication, occlusive coronary artery disease, exercise-induced hypertension and cardiac dysrhythmias.¹⁶

Iridology

Iridology can be used to detect the presence of arcus senilis (a whitish ring at the perimeter of the cornea), which is highly suspicious of hypercholesterolaemia in clients under 40 years of age.¹⁰ The sign is also predictive of CVD and coronary artery disease in older people, yet, given that arcus senilis is strongly associated with increasing age, the sign may be misleading in this population.²¹

Respiratory system assessment

The respiratory system is divided into two sections – the upper and lower respiratory tracts. The upper tract consists of the nose, paranasal sinuses, nasal cavity and pharynx, while the lower tract includes the larynx, trachea, bronchi, bronchioles, alveoli and lungs. The respiratory system is primarily responsible for gas exchange, in particular, the uptake of oxygen from the atmosphere and the elimination of carbon dioxide into the external environment. When the functional capacity of this system is comprised, hypoxia, hypercapnia and waste accumulation can occur.

A practitioner should consider these points when conducting a comprehensive assessment of the respiratory system. An outline of the regions pertinent to respiratory system assessment is illustrated in Figure 3.3.

Figure 3.3 Respiratory assessment cue card

Health history

History of presenting condition

The practitioner should ascertain the client’s primary problem and determine the location, onset, duration, frequency, quality and severity of the sign or symptom, the presence of radiating symptoms, any aggravating or ameliorating factors (such as exercise, cold air, cigarette smoke, dietary factors or medication) and any concomitant symptoms (including fatigue, dyspnoea, dyspepsia, pain, cough, nasal discharge, haemoptysis, fever and hoarseness).

Medical history

Family history

Ascertain whether the client is at risk of respiratory illness or if the presenting condition can be explained by genetic predisposition by assessing if there is a family history of respiratory complaints such as asthma, chronic obstructive pulmonary disease (COPD) and atopic disease.

Allergies

Establish whether the client has any sensitivities or is allergic to medications (such as antibiotics), foods (such as peanuts) and environmental substances (such as pollen, animal dander or dust mite) that could contribute to the presenting complaint or affect on clinical management.

Medications

Establish whether the client is currently taking or has recently completed any over-the-counter or prescribed medications, herbs, supplements or therapies for respiratory illness, including bronchodilators, antibiotics, inhaled corticosteroids, expectorants, decongestants, antitussives and oxygen. It is also essential to determine if there are any treatments that may generate respiratory-type symptoms (i.e. angiotensin conventing enzyme (ACE) inhibitor-induced cough, fluoxetine-induced pneumonia, amiodarone-induced pneumonitis).

Medical conditions

Identify any current or previous medical conditions that involve the upper and lower respiratory tracts, such as asthma, bronchitis, bronchiectasis, pneumonia, emphysema, rhinosinusitis, tonsillitis, pharyngitis, laryngitis or neoplastic disease. In addition, determine if there are any conditions that could yield respiratory-type symptoms or mimic respiratory disease (including anaemia, anxiety, gastro-oesophageal reflux disease, musculoskeletal complaints or cardiac failure).

Surgical and investigational procedures

Determine whether the client has undergone any surgical or investigational procedure in the past (such as rhinoplasty, thoracotomy, bronchoscopy or tracheotomy) to ascertain if there are any other respiratory conditions that may have been overlooked in the health history.

Lifestyle history

Identify any lifestyle determinants that may exacerbate, prolong or increase a client’s risk of upper or lower respiratory tract illness, particularly tobacco use (including number and strength of cigarettes inhaled in a day) and level of physical activity,²² and diet and fluid intake (i.e. sodium, tea, fruit and vegetable consumption).²³

Socioeconomic background

Ascertain if there are any socioeconomic factors that may increase the client’s risk of respiratory disease, affect their understanding of the condition or the management of the disease, such as residential and/or work environment (i.e. whether the client resides near an industry or arterial road, whether they are exposed to dust, asbestos, silica, chemicals or other respiratory irritants or whether any people in the household smoke), family environment (i.e. marital status, number and ages of children), occupation and employment status (i.e. day or nightshift, full or part time, number of jobs), religion, ethnicity, race or cultural background (i.e. whether the client follows strict dietary practices, whether the client’s culture, race or ethnic background place the client at increased risk of developing respiratory disease), level of social support (i.e. whether the client lives alone or receives community services) and level of educational attainment (i.e. primary, secondary and/or tertiary education).

Physical examination

Inspection

Assess the quality of respirations, taking particular note of the rate (an accelerated respiratory rate may be a sign of anxiety, fever, metabolic acidosis or airway obstruction; bradypnoea may signify liver failure, diabetic ketoacidosis or increased intracranial pressure), rhythm (an irregular breathing pattern, such as Cheyne-Stokes or Biot’s breathing, may suggest brain damage or drug-induced respiratory depression),¹⁰ depth (hyperpnoea, or deep breathing, may occur in metabolic acidosis; shallow breathing can be a sign of pneumonia, pulmonary oedema, COPD or pleurisy) and effort of respirations (laboured breathing may occur in chronic obstructive pulmonary disease). The clinician should also observe for signs of clubbing (an abnormal enlargement of the terminal phalanges that may be indicative of chronic hypoxia), central cyanosis (a bluish tinge to the lips and tongue that may signify reduced arterial oxygenation, which can occur in severe airflow limitation or pulmonary fibrosis),¹² finger or fingernail staining (brown-yellow staining of the fingers can indicate a history of cigarette smoking), nasal flaring, accessory muscle use and intercostal retraction (these signs are indicative of airway obstruction and/or respiratory distress), tracheal asymmetry (tracheal deviation may occur in upper lobe lung disease, such as tension pneumothorax),²⁴ chest wall asymmetry (asymmetrical movement of the chest may signify impaired air entry from localised pulmonary consolidation, collapse, fibrosis or effusion)²⁴ and chest wall deformities (pectus carinatum may develop following severe respiratory illness in childhood; barrel chest may occur in chronic obstructive pulmonary disease).¹² Other noteworthy observations that may allude to previous respiratory dysfunction include body position (whether the client finds it difficult to breathe when lying down on the examination table), flow of conversation (whether the client can maintain a normal conversation without becoming short of breath), pharyngeal mucosa (whether there is pharyngeal erythema or tonsillar enlargement), scarring (whether there is evidence of previous thoracic surgery (i.e. thoracoplasty) and trauma (whether there are chest drain scars from previous pneumothorax or haemothorax). For paediatric clients, the practitioner should also observe for the presence of foreign bodies in the ear, nose and throat.

Olfaction

During the clinical examination, the clinician should note the presence of halitosis, or foul-smelling breath. This symptom may allude to the existence of dental, gingival, sinus, oral, oesophageal or respiratory pathology. In terms of the latter, this can include respiratory tract infection, lung abscesses and bronchiectasis.

Palpation

Palpate the paranasal sinuses (localised tenderness may indicate sinusitis), the position of the trachea (tracheal deviation may suggest a mediastinal shift), the presence of chest wall masses, sinus tracts and discomfort (chest/intercostal tenderness may be associated with pleurisy and/or underlying musculoskeletal disease; sinus tracts may indicate tuberculosis or actinomycosis),⁹ and the size, shape, mobility and tenderness of lymph nodes (tender and mobile lymph nodes are suggestive of infection and/or inflammation).⁹ The degree of symmetry of respiratory expansion is another important technique that can aid the detection of localised pulmonary disease, such as pneumonia or bronchial obstruction. The density of underlying tissue can be determined by palpating the chest wall for tactile fremitus (vibrations transmitted from voice sounds to the chest wall may be reduced in the presence of liquid, gas and excess adipose tissue, and increased in solid or consolidated areas).¹⁰

Percussion

Much like tactile fremitus, percussion is also used to assess the density of underlying tissues up to a depth of 5–7 centimetres. Percussion can help to confirm or refute any abnormal findings identified during palpation. Percussive tones that may be detected include flatness (short, high pitch tone over a fluid-filled region, such as pleural effusion), dullness (medium duration and medium pitch tone over a solid area, such as pneumonia), resonance (long, low pitch tone over normal lung) and hyperresonance (long, low pitch tone over an air-filled structure, such as pneumothorax).²⁴

Auscultation

The auscultation of breath sounds is an important component of the respiratory assessment as it provides valuable information about airflow. Using the diaphragm of a stethoscope, examine the quality, location, intensity and duration of breath sounds, including the presence of vesicular breath sounds (soft, low pitch breath sounds normally heard over most parts of the lungs) and bronchial breath sounds (the presence of these loud, high-pitch sounds over areas other than the manubrium may indicate lung consolidation).²⁴ Additional cues about underlying pathology can be determined from adventitious sounds such as stridor (due to narrowing or obstruction of the larynx or trachea), crackles (from excess airway secretions, as in respiratory tract infection and pulmonary oedema), wheezes (resulting from narrowed or obstructed airways), rhonchi (from transient airway plugging, as in bronchitis) and pleural rub (due to pleural inflammation).¹⁰ Auscultation also can be used to assess the density of underlying tissue by examining the quality of transmitted voice sounds. The existence of bronchophony (when the spoken words ‘ninety-nine’ become loud and clear), aegophony (when the spoken sound ‘ee’ sounds like ‘ay’) and/or whispered pectoriloquy (when the whispered words ‘ninety-nine’ become loud and clear) over any part of the chest is suggestive of lung consolidation.⁹

Additional signs

Clinical data not derived from the abovementioned physical examination, which can support suspicions of infectious disease, can be derived from assessing core body temperature.

Clinical assessment tools

Examples of instruments that may be used to evaluate the severity or effect of respiratory complaints, or the effect of treatment on these conditions, are as follows.

Asthma control scoring system (ACSS)

Quantitatively evaluates the level of asthma control by providing percentage scores for clinical, physiologic and inflammatory parameters.

Clinical chronic obstructive pulmonary disease questionnaire (CCQ)

Measures the severity, degree of functional limitation and level of clinical control in clients with COPD.

Cystic fibrosis questionnaire (CFQ)

Measures the effect of cystic fibrosis on overall health, activities of daily living and wellbeing.

Influenza symptom severity (ISS) scale

Assesses the intensity of influenza symptoms.

Rhinosinusitis disability index (RDI)

Evaluates the physical, functional and emotional effects of nasal and sinus disorders on health-related quality of life.

Wisconsin upper respiratory symptom survey (WURSS)

Assesses the severity and functional effect of the common cold, as well as changes in symptoms over time.

Diagnostics

Pathology tests

Arterial blood gases (ABG)

An ABG test is useful in assessing ventilatory function and acid–base balance. The test measures the pH, oxygen saturation, bicarbonate level and partial pressures of oxygen (pO₂) and carbon dioxide (pCO₂) in the blood. ABG findings pertinent to the respiratory system are as follows:

• elevated pH (may occur in respiratory alkalosis, cystic fibrosis, pulmonary emboli, acute pulmonary disease)

• decreased pH (suggestive of respiratory acidosis and respiratory failure)

• increased pCO₂ (indicative of COPD)

• reduced pCO₂ (may occur in pulmonary emboli).¹⁶

Hair, urine, serum and blood nutrient levels

These nutrient tests may be indicated when presenting clinical manifestations are suggestive of nutrient deficiency or toxicity, when the presenting condition is likely to be caused by nutrient deficiency or toxicity or when the condition is likely to contribute to the development of nutrient deficiency or toxicity. Nutrient tests that are particularly relevant to respiratory assessment are hair mineral analysis, serum vitamin A, serum pyridoxine and serum calcium.

Sputum culture and sensitivity testing

Testing of a fresh sputum specimen enables sufficient numbers of the organism to be isolated, identified and quantified, and the antibiotics to which the microbial strains are sensitive or resistant to be determined. This test may be ordered for the purpose of aiding the diagnosis and treatment of bacterial, viral or fungal infection of the respiratory tract.¹⁶

Radiology tests

Chest X-ray (CXR)

CXR uses electromagnetic radiation to produce images of the chest wall, lung fields, bones and diaphragm; it can also be used to detect abscesses, atelectasis, bronchitis, COPD, lymphadenopathy, tumours, pleural effusion, pleuritis, pneumonia, pulmonary oedema, haemo/pneumothorax, pulmonary fibrosis and tuberculosis.²⁰

Computed tomography (CT)

CT uses multiple X-ray beams to produce cross-sectional images of the lungs, mediastinum, bronchi, pleural space and bones; it is also a useful radiological test for identifying tumours, lesions, cysts, pleural effusion, pneumonitis, lymphadenopathy, inflammatory nodules and bronchial stenosis or dilatation.

Magnetic resonance imaging (MRI)

MRI uses magnetic and radiofrequency energy to generate images of the lungs, pleural space, soft tissues and bones, and together with appropriate agents, can also assess lung perfusion and ventilation. While MRI can be used to detect pleural effusion, tumours, lung malformations, pneumonia, asbestosis and lung fibrosis, motion artefacts are a current concern with chest MRI.²⁵

Ventilation–perfusion (VQ) scan

A VQ scan uses intravenous radioactive material to assess pulmonary blood flow and perfusion, and an aerosolised agent (such as Krypton gas) to measure the patency of pulmonary airways. A VQ mismatch (i.e. normal ventilation and abnormal perfusion) is indicative of pulmonary embolus, whereas abnormal ventilation and perfusion findings are suggestive of pneumonia, emphysema and/or pleural effusion.¹⁶

Functional tests

Pulmonary function tests (PFTs)

PFTs are often performed to evaluate the presence and severity of respiratory disease. The PFT can incorporate any number of different measures of lung volume and capacity, including total lung capacity, tidal volume, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), maximal mid-expiratory flow (MMEF), maximal volume ventilation (MVV), peak inspiratory flow rate (PIFR) and peak expiratory flow rate (PEFR). Reductions in many of these measures are often evident in asthma, emphysema, chronic bronchitis, bronchiectasis and other obstructive pulmonary diseases.¹⁶

Invasive tests

Bronchoscopy

This is an endoscopic procedure that enables direct visualisation of the trachea, larynx, bronchi, bronchioles and alveoli. As a diagnostic tool, bronchoscopy is useful in detecting tumours, inflammatory disease, foreign bodies, structural anomalies, abscesses, interstitial pulmonary disease, strictures, tuberculosis and opportunistic lung infections. Bronchoscopy also plays an important role in the collection of tissue biopsies.²⁰

Thoracentesis, or pleural tap

In this procedure, a needle is inserted into the pleural cavity for the purpose of removing fluid or gas. As a diagnostic tool, thoracentesis is used to determine the aetiology of a pleural effusion such as empyema, pneumonia, tuberculosis, pulmonary infarction, malignancy and haemothorax.¹⁶

Gastrointestinal system assessment

The gastrointestinal system consists of a number of structures that can be categorised into two parts. The first of these is the gastrointestinal (GI) tract, which incorporates the mouth, oesophagus, stomach, duodenum, jejunum, ileum, caecum, colon, rectum and anus. The remaining parts are collectively known as the accessory structures, which include the tongue, teeth, salivary glands, pancreas, gallbladder and liver. The principle roles of the GI system are ingestion, digestion, absorption, secretion and elimination.

Any deviation from normal GI integrity or physiology may manifest as abnormal changes in these functions. These points should be taken into consideration when conducting a comprehensive assessment of the gastrointestinal system. An outline of the regions pertinent to gastrointestinal system assessment is illustrated in Figure 3.4.

Figure 3.4 Gastrointestinal assessment cue card

Health history

History of presenting condition

After establishing the client’s primary problem, ascertain the location, duration, frequency, onset, quality and severity of the sign or symptom, the presence of radiating symptoms (i.e. right upper quadrant pain radiating to the right inferior scapula is suggestive of cholelithiasis),²⁶ any aggravating or ameliorating factors (such as emotional stress, alcohol, dietary components, exercise, defecation, meal consumption, cigarette smoking, distinct odours, medications or movement) and any concomitant symptoms (including fatigue, fever, diarrhoea, constipation, nausea, vomiting, odynophagia, halitosis, weight change, pain, flatulence, bloating, dysphagia, tenesmus, dyspepsia, anorexia, abdominal distension and cramping).

Medical history

Family history

Determine whether the client is at risk of GI disease or if the presenting condition can be explained by genetic predisposition by asking if there is any family history of GI illness, such as inflammatory bowel disease (IBD), colon cancer, irritable bowel syndrome (IBS), gastroenteritis or coeliac disease.

Allergies

Ascertain whether the client has any allergies or sensitivities to foods (such as lactose, gluten, soy, nuts, corn, dairy or eggs), medications (such as antibiotics) and environmental substances (such as molds or pollens) that could contribute to the presenting complaint or affect on clinical management.

Medications

Determine whether the client is currently administering, or has recently completed, any over-the-counter or prescribed medications, supplements, herbs or therapies for a GI complaint (i.e. aperients, antibiotics, antispasmodics, antidiarrhoeals, antacids, digestive enzymes, probiotics, anorectal agents, gastric acid suppressants). The clinician should also note if there are any treatments that may generate GI symptoms (i.e. antibiotic-associated diarrhoea, aperient-associated diarrhoea, non-steroidal anti-inflammatory drug-induced gastritis).

Medical conditions

Ascertain if there are any previous or current medical conditions that involve the GI tract and accessory structures, including appendicitis, carcinoma, coeliac disease, cirrhosis, cholelithiasis, constipation, cystic fibrosis, dental caries, diverticulosis, dyspepsia, gastritis, gastroenteritis, gastro-oesophageal reflux disease, gingivitis, haemorrhoids, hepatitis, IBD, IBS, liver failure, pancreatitis, peptic ulceration and peritonitis. Also establish if there are any complaints that could yield GI-type symptoms or mimic GI illness (such as anxiety, aperient abuse, depression, diabetes mellitus, eating disorders, electrolyte disturbance, neuromuscular disease, nutrient deficiency or thyroid disorder).

Surgical and investigational procedures

Establish whether the client has undergone any investigational or surgical procedure in the past (such as endoscopy, colonoscopy, laparoscopy, laparotomy, appendicectomy, cholecystectomy, stoma formation or bowel resection) to discover other GI conditions that may have been missed in the health history.

Lifestyle history

Identify any factors that may increase the client’s risk of GI illness or exacerbate the presenting complaint, such as tobacco use (including number and strength of cigarettes inhaled in a day),²⁷ alcohol consumption (including number of standard drinks and type of alcoholic beverage consumed in a day),²⁸ illicit drug use (including type, route and quantity of drug used per day), diet and fluid intake (such as fibre, fruit and vegetable consumption, dairy and wheat intake),^26,²⁹ quality and duration of sleep (e.g. broken sleep, sleep apnoea),³⁰ and frequency, duration and type of exercise.³¹

Socioeconomic background

Determine whether there are any socioeconomic factors that may increase the client’s risk of GI illness, affect their understanding of the condition or the management of the complaint, such as occupation and employment status (i.e. day or nightshift; full or part time, number of jobs, hours worked each week), residential and/or work environment (i.e. do these environments create significant emotional stress?), family environment (i.e. marital status, number and ages of children), religion, ethnicity, race or cultural background (i.e. whether the client follows stringent dietary practices, whether the client’s culture, race or ethnic background place the client at increased risk of developing GI disease), level of social support (i.e. whether the individual lives alone or receives community services) and level of educational attainment (i.e. primary, secondary and/or tertiary education).

Physical examination

Inspection

Observe for any signs of previous or existing impairment to GI structure and/or function, beginning with examination of the oral cavity, including the lips (i.e. angular stomatitis), tongue (i.e. candidiasis, carcinoma, glossitis), palate (i.e. torus palatinus), gingivae (i.e. gingivitis, ulceration, bleeding), teeth (i.e. caries) and oropharynx (i.e. tonsillitis, pharyngitis). This examination is particularly important as these structures play an essential role in chemical and mechanical digestion, and furthermore, can manifest early signs of nutritional imbalance and/or deficiency. Inspection of the skin and sclera may also detect the presence of jaundice that may be secondary to haemolysis or liver disease.²⁴ For paediatric clients, the buccal mucosa should be assessed for the presence of Koplik’s spots (small white spots indicative of measles), the soft palate should be inspected for Forschheimer’s spots (small dusky red spots that may arise at the onset of rubella), and the number and condition of the teeth recorded.¹⁰

The abdomen should then be observed for scars (from previous surgery or trauma), striae (such as the pink purple striae of Cushing’s syndrome), dilated veins and/or spider naevi (due to liver disease), everted umbilicus (due to late pregnancy, ascites or large mass), ecchymosis (bluish discolouration of the flanks and/or periumbilicus secondary to haemoperitoneum), rashes, peristalsis (visible peristalsis may indicate intestinal obstruction), lesions, asymmetry (due to organomegaly or masses), contour and herniation.⁹ Where appropriate, the anus and perianal region should be inspected for signs of underlying pathology, such as haemorrhoids (may be indicative of constipation), lichenification (suggestive of pinworm infection), excoriation (a manifestation of chronic diarrhoea) and fistula formation (a sign of IBD). Because of the potential risk of litigation with this technique, this aspect of the examination should be restricted to clinicians who are qualified to perform this assessment.

Olfaction

The presence of abnormal odours from the GI tract may highlight signs of underlying pathology. Fetid smelling stools, for instance, may suggest the presence of malabsorption syndrome, steatorrhoea, cystic fibrosis, coeliac disease, intestinal dysbiosis or GI infection. Halitosis may be indicative of tobacco use, poor oral hygiene, dental disease, mouth ulceration, liver disease, dry mouth, carcinoma, GORD, bowel obstruction or infection.²⁴

Palpation

Light and deep palpation is used to assess the position, shape, mobility, consistency, tenderness and size of the liver, spleen and abdominal contents, as well as any masses.⁹ Particularly useful signs of underlying pathology are Murphy’s sign (the existence of right upper quadrant pain subsequent to right subchondral pressure and deep inspiration, which is suggestive of cholecystitis), Rovsing’s sign (the occurrence of right lower quadrant pain following the application of left lower quadrant pressure, which is a sign of appendicitis) and rebound tenderness (the presence of abdominal pain following the rapid withdrawal of deep pressure, which may be indicative of peritoneal irritation). The presence of voluntary guarding and/or involuntary muscle spasm or rigidity is also suggestive of an irritated peritoneum.¹⁰ Qualified clinicians may choose to perform a rectal examination to detect the presence of haemorrhoids, rectal prolapse, fissures, fistulas and carcinoma of the anus.²⁴

Percussion

This technique can be applied to assess the size and location of masses and organs (which produce a dull percussive tone), and fluid or air-filled regions (which produce a tympanic percussive tone).⁹

Auscultation

The pitch and frequency of bowel sounds can allude to changes in GI function. Hyperactive bowel sounds, for instance, may be suggestive of diarrhoea or early intestinal obstruction, whereas hypoactive or absent bowel sounds may indicate peritonitis and paralytic ileus.²⁴

Additional signs

Clinical data not derived from the physical examination, which can provide important information about the aetiology of a presenting condition, as well as the general health and nutritional status of the client, can be derived from the assessment of core body temperature, weight, height, BMI, waist circumference and skinfold thickness.

Assesses carbohydrate malabsorption, orocecal transit time and small intestinal bacterial overgrowth (SIBO). The test requires the client to consume a specified dose of carbohydrate (lactulose, lactose, fructose, glucose), which the intestinal bacteria metabolise into hydrogen and/or methane. After ingestion, a series of breath samples is taken over a 2–4 hour period. The increased presence of exhaled hydrogen and/or methane (typically over 20 parts per million) is suggestive of carbohydrate malabsorption and possibly SIBO. The sensitivity and specificity of this test for SIBO is currently inadequate for routine clinical use.³³

Helicobacter pylori breath test or urea breath test

A highly specific and sensitive test for detecting H. pylori infection as a cause of peptic ulceration, gastric carcinoma and gastritis that requires the oral administration of radiolabelled carbon and urea, which, in the presence of H. pylori, is converted into CO₂. The radiolabelled CO₂ is exhaled after 30 minutes, collected and tested.²⁶

Culture and sensitivity testing

This type of testing of a fresh stool specimen enables sufficient numbers of an organism to be isolated, identified and quantified, and the antibiotics that the microbial strains are sensitive or resistant to, to be determined. This test may be ordered to aid the diagnosis and treatment of bacterial, viral, fungal, protozoan or parasitic enterocolitis.¹⁶

Faecal analysis

This test examines a number of stool characteristics, including appearance, colour, occult blood (present in carcinoma, inflammatory bowel disease, upper GI disease and diverticular disease), epithelial cells (elevated in IBD), leucocytes (increased in intestinal infections), carbohydrates (present in malabsorption syndromes), fat (a sign of fat malabsorption), meat fibres (present in altered protein digestion) and trypsin (reduced in malabsorption syndromes, cystic fibrosis and pancreatic deficiency).¹⁸

Hair, urine, serum and blood nutrient levels

These tests may be indicated when presenting clinical manifestations are suggestive of nutrient deficiency or toxicity, when the presenting condition is likely to be caused by nutrient deficiency or toxicity or when the condition is likely to contribute to the development of nutrient deficiency or toxicity. Nutrient tests that are particularly relevant to GI assessment are hair mineral analysis, iron studies, red blood cell folate, serum α-tocopherol, serum vitamin A, serum vitamin B₁₂, serum vitamin C, serum calcium, serum cholecalciferol, serum magnesium, serum phylloquinone, serum pyridoxine and serum zinc.

Liver function test (LFT)

A LFT provides information about liver function (i.e. total protein, albumin, bilirubin, ammonia) and hepatocyte integrity (i.e. alkaline phosphatase (ALP), gamma glutamyl transpeptidase (GGT), alanine amino transferase (ALT), aspartate amino transferase (AST)). Results of the LFT can assist in the diagnosis of alcohol abuse, cirrhosis, hepatitis, liver disease, biliary disease, malnutrition and malabsorption.³⁴

CT uses multiple X-ray beams to generate cross-sectional images of the abdomen and pelvis, thus enabling the detection of tumours, cysts, bowel obstruction, bleeding, pancreatitis, cirrhosis, fatty liver, diverticulitis, colonic polyps, cholelithiasis and ductal obstruction or dilatation.¹⁸

Lower GI series, or barium enema

Provides serial X-ray images of the colon and distal ileum using rectally administered barium contrast media to enhance visualisation. A lower GI series can be ordered to facilitate a diagnosis of carcinoma, IBD, polyps, diverticula, structural defects, perforation, fistula formation, appendicitis and herniation.¹⁶

Magnetic resonance imaging (MRI)

MRI uses magnetic and radiofrequency energy to produce images of the organs and soft tissues of the abdomen and pelvis that can be useful in detecting tumours, pancreatitis, cholangitis, peritonitis, abscesses, cirrhosis, fatty liver, diverticulitis, cholelithiasis and ductal obstructions or dilatation.¹⁸

Ultrasound

Ultrasound uses sound waves to assess the size, position, contour and texture of the organs of the abdomen and pelvis in order to detect conditions such as pancreatitis, ductal obstructions or dilatation, cysts, tumours, cirrhosis, cholecystitis, cholelithiasis, hepatitis and peritonitis.¹⁸

Upper GI series, or barium swallow

Provides serial X-rays of the lower abdomen, stomach and duodenum using orally administered barium contrast media to enhance visualisation. This test is particularly useful for detecting tumours, oesophageal varices, hiatus hernia, perforation, strictures, congenital defects, peptic ulceration, motility disorders and diverticula.²⁰

Functional tests

Comprehensive detoxification profile, or functional liver detoxification profile

Measures the rate of phase I and phase II liver detoxification following caffeine, aspirin and paracetamol challenge. Findings from this test, such as a reduction in the rate of substance clearance, can provide important insight into a client’s liver function, specifically, whether a client is able to effectively clear toxic metabolites from the blood.³⁵

Comprehensive digestive stool analysis (CDSA)

CDSA obtains data on enzymatic digestion, fatty acid absorption, microbiological balance and metabolic markers of disease, and may help to determine the presence of intestinal dysbiosis, intestinal candidiasis, nutrient malabsorption and indigestion.³⁶

Intestinal permeability test

This test assesses small intestine absorption and permeability by measuring urinary elimination of lactulose and mannitol 6 hours after oral administration. Increased elimination of these non-metabolised sugars in the urine may be indicative of leaky gut syndrome and impaired intestinal permeability, whereas reduced urinary elimination may suggest malabsorption.³⁷

Invasive tests

Abdominal paracentesis, or peritoneal tap

Requires the insertion of a sterile needle into the peritoneal cavity for the purpose of removing fluid. As a diagnostic tool, the procedure is used to determine the aetiology of peritoneal effusion, such as carcinoma, peritonitis, pancreatitis, tuberculosis, lymphoma and perforation.¹⁶

Biopsy

A biopsy involves the excision of a small sample of tissue and the subsequent microscopic examination of the sample in order to identify cell morphology and tissue abnormalities. A biopsy of GI tissue may assist in the diagnosis of cancer, infection, inflammation, cirrhosis, coeliac disease and lactose deficiency.¹⁸

Colonoscopy

Permits direct visualisation of the colon, ileocecal valve and terminal ileum through the use of a flexible fiberoptic colonoscope. Colonoscopy can be used to determine the presence of tumours, polyps, inflammation, diverticula, haemorrhoids, ulceration and bleeding.²⁰

Endoscopic retrograde cholangiopancreatography (ERCP)

ERCP enables direct and radiographic visualisation of the biliary and pancreatic ducts through the use of a fiberoptic endoscope, X-ray imaging and contrast media. As a diagnostic procedure, ERCP can identify the presence of obstructive jaundice, duodenal papilla carcinoma, pancreatitis and pancreatic or biliary duct abnormalities, calculi, stenosis or cysts.¹⁶

Gastric acid stimulation test

Measures the volume and pH of gastric acid before and after administration of a gastric acid stimulant, such as pentagastrin. Nasogastric aspirates of stomach acid are analysed to determine the cause of peptic ulceration, pernicious anaemia or gastrinoma, the efficacy of ulcer treatment and the presence of hyper- or hypochlorhydria.¹⁸

Laparoscopy

Through the use of a rigid fibreoptic laparoscope, enables direct visualisation of the peritoneal cavity and abdominal organs, including the stomach, liver, gallbladder, pancreas and intestines. The procedure is helpful in detecting tumours, adhesions, cirrhosis, lymphomas, perforation, inflammation and infection.²⁰

Oesophagogastroduodenoscopy (OGD)

OGD uses a fibreoptic endoscope to examine the upper GI tract, including the oesophagus, stomach and duodenum. Capsule endoscopy, which uses an orally administered capsule camera, is also capable of visualising the jejunum and ileum. Both endoscopic procedures are useful in detecting oesophageal varices, diverticula, duodenitis, oesophagitis, gastritis, hiatus hernia, peptic ulceration, tumours, bleeding, stenosis and polyps.¹⁸

Sigmoidoscopy

Uses a flexible or rigid sigmoidoscope to directly visualise the anus, rectum and sigmoid colon, which can be helpful in detecting tumours, polyps, haemorrhoids, ulceration and bleeding.¹⁶

Urinary system assessment

The urinary system comprises the kidneys, ureters, urinary bladder and urethra. While the urinary system is primarily responsible for the elimination of waste products, it is also essential for maintaining homeostasis. Hence, adverse changes to the structure or function of this system will almost certainly lead to an inability to fulfil these roles and the subsequent manifestation of adverse signs and symptoms.

These considerations should be borne in mind when conducting a comprehensive assessment of the urinary system. An outline of the regions pertinent to urinary system assessment is illustrated in Figure 3.5.

Figure 3.5 Urinary assessment cue card

Health history

History of presenting condition

Identify the client’s primary problem and establish the quality, severity, onset, location, duration and frequency of the sign or symptom, the presence of radiating symptoms (i.e. pain radiating from the flank, across the abdomen and down the inner thigh is suggestive of urinary calculi),²⁶ any aggravating or ameliorating factors (such as fluid consumption, constipation, body position, cigarette smoking, spices, alcohol or caffeine) and any concomitant symptoms (including urinary frequency, urgency, tenesmus, dysuria, nocturia, enuresis, haematuria, hesitancy, dribbling, incontinence, loin pain, pneumaturia, polyuria, pyrexia, oliguria, oedema, and any changes in urine colour, odour, turbidity, force and calibre of stream).

Medical history

Family history

Establish whether the individual has a genetic predisposition to urinary tract disease by assessing whether the client has any family history of urological illness, including polycystic kidney disease, carcinoma of the urinary tract, interstitial cystitis, nephrotic syndrome or pyelonephritis.

Allergies

Discover whether the client has any sensitivities or allergies to medications (such as antibiotics), foods (such as gluten) and environmental substances (such as insect stings) that could contribute to the presenting condition or affect clinical management.

Medications

Ascertain whether the client is presently administering, or has recently finished, any over-the-counter or prescribed medications, supplements, herbs or therapies for a urological complaint, including urine alkalinisers or acidifiers, diuretics, antibiotics, antispasmodics, urinary antiseptics and 5-alpha reductase inhibitors. The practitioner should also note the use of treatments that may contribute to urinary tract symptoms, such as anticholinergic drug-induced urinary retention, diuretic-induced polyuria, and prazosin-associated urinary incontinence.

Medical conditions

Establish if there are any current or previous medical conditions that involve the kidney, bladder or urinary tract, such as cancer, cystitis, benign prostatic hypertrophy, hydronephrosis, glomerulonephritis, nephritic/nephrotic syndrome, nephropathy, polycystic kidney disease, pyelonephritis, renal failure, urinary tract infection, urinary calculi or urinary incontinence. The presence of conditions that could yield urinary-type symptoms or mimic urological disease (including bowel–urinary tract fistula, dehydration, diabetes insipidus, epididymitis, neuromuscular disease, pregnancy and vaginitis) should also be ascertained. A history of urethral/suprapubic catheterisation or renal dialysis may also allude to the presence of other urological defects.

Surgical and investigational procedures

Determine whether the client has undergone any pertinent surgical or investigational procedures in the past (such as biopsy, cystoscopy, pyelogram, laparoscopy, removal of urinary calculi or transurethral resection of the prostate) to identify other urological conditions that may have been overlooked in the health history.

Lifestyle history

Establish if there are any factors that may increase the individual’s risk of urological disease or worsen the presenting complaint, such as obesity,³⁸ tobacco use (including number and strength of cigarettes inhaled in a day),³⁹ alcohol consumption (including number of standard drinks and type of alcoholic beverage consumed in a day),⁴⁰ illicit drug use (including type, route and quantity of drug used per day), diet and fluid intake (such as fruit and vegetable consumption, simple sugar intake, omega 3 fatty acid consumption),^39,⁴⁰ quality and duration of sleep (e.g. broken sleep, sleep apnoea)⁴¹ and frequency, duration and type of exercise.⁴²