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)

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)

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)

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)

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:

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

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

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

Physical examination