AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset When did you first notice the cough? After I had a cold last month. Timing How often do you cough? Every day. Exacerbating factors What makes it worse? When I run around and at night. Relieving factors What makes it better? When I stay inside and during the day. Examination and inspection Physical examination reveals bilateral tenderness of cervical lymph nodes.

TABLE 6.2 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
To Jake’s mum: Is there a family history of asthma?	Jake’s cousin has asthma.
Allergies and irritants	Jake’s mum answers:
Are there symptoms of sneezing or nose discharge, conjunctivitis and itching on the roof of the mouth with the cough? (allergies)	No, not much in terms of sneezing or runny nose or eye symptoms.
Infection and inflammation	Jake’s mum answers:
Is the cough ever worse in the morning? (PND, chronic bronchitis)	It seems to be getting worse during the night, but he doesn’t cough more in the morning.
Stress and neurological disease	Jake’s mum answers:
So if I understand correctly, the cough is disturbing sleep and does not improve at night? (may rule out psychogenic, habit cough, Tourette’s syndrome)	Yes, that’s right, it seems to definitely worsen during the night but I’m not sure if that’s because of how cold his room gets at night sometimes.
Eating habits and energy	Jake’s mum answers:
Tell me about Jake’s diet and his energy levels.	He eats whatever I give him, but doesn’t like vegetables very much. He has Weet-Bix and milk for breakfast and usually a cheese sandwich for lunch. I send fruit to school every day but he usually brings it home. He would eat McDonald’s every day if we let him, but we don’t.
	He is usually full of energy, but he seems to be a bit lethargic recently.

TABLE 6.3 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Emotional health
To Jake’s mother:
Do you think Jake might be a bit stressed? Can you tell me about that?	There has been a bit of conflict between Jake’s dad and myself. I would like to live closer to my family, but he really loves it where we are and wants to stay.
Daily activities
To Jake:
Tell me what you do every day.	I go to school and when I get home I muck around with my friends or watch TV.
Family and friends
To Jake:
Tell me about your friends and family.	Tim and Ryan live up the road so we hang out a lot. My cousins live in the city so I see them sometimes on the weekend or in the holidays.
Action needed to heal
To Jake:
I know you’d like to get rid of your cough and have more energy again. Do you think you’d be willing to take some medicine and do some things I suggest to help you get better?	Depends if I like it.

TABLE 6.4 JAKE’S SIGNS AND SYMPTOMS [1–3]

Pulse	100 bpm (normal pulse for a child is 80–120 bpm)
Blood pressure	110/77 sitting with child cuff
Temperature	37°C
Respiratory rate	14 resp/min (15–30 resp/min is usual for a child)
Body mass index	20 (85th percentile for an 11-year-old boy)
Face	Red
Physical examination	Cervical nodes small and tender on both right and left sides
Urinalysis	No abnormality detected (NAD)

Results of medical investigations

No investigations have been carried out.

TABLE 6.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2–4, 63]

CONDITIONS AND CAUSES	WHY UNLIKELY
INFECTION AND INFLAMMATION
Acute viral upper respiratory tract infection	No fever, cough has been present for more than 2 weeks
Acute bronchitis	No fever, cough has been present for more than 2 weeks
Tuberculosis	No fever, cough has been present for more than 2 weeks
Pneumonia	No fever, cough has been present for more than 2 weeks

Case analysis

TABLE 6.6 POSSIBLE DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [2, 4, 5, 10–13, 63, 64, 66–68, 76, 77]
CONDITION	WHY POSSIBLE	WHY UNLIKELY
ALLERGIES AND IRRITANTS
Chronic allergies, irritants [64, 65]	Lives in the country, could be near irritants and pollutants such as pollens, dust and farming practices or chemicals that could trigger allergies or bronchial irritation; Jake may be exposed to chlorine and swimming pools	No history of hay fever, sinus or seasonal allergies
CANCER AND HEART DISEASE
Carcinoma: leukaemia, carcinoma of oesophagus, larynx, trachea, bronchi, alveoli, pleura	Persistent cough	Rare
TRAUMA AND PRE-EXISTING ILLNESS
Causal factor: Trauma/physical abuse: from rib fracture, laceration, haemorrhage, inhalation of foreign object	Persistent cough, stress at home	No signs or symptoms of associated body pain or trauma as yet
FUNCTIONAL DISEASE
Cystic fibrosis	Can present in school-aged children, breathlessness, recurrent chest infections	No sign of sinusitis, mucus in bowel motions, blood in sputum
Gastro-oesophageal reflux	Common cause of persistent recurrent cough; can be worse after eating chocolate or caffeinated foods/drink can be exercise induced	Usually occurs in adults and presents with a non-productive cough; usually worse on waking and after eating
INFECTION AND INFLAMMATION
Asthma: postviral	Children with recurrent cough are often asthmatic; Jake’s recent upper respiratory tract infection was most probably viral (antibiotics did not completely resolve it); family history of asthma; productive cough that is persistent and subacute with clear thick mucus; cough is worse at night, in the cold and on exertion; stressful time at home with parents fighting; shortness of breath is associated with the cough in cold weather
Chronic bronchitis: viral, bacterial, allergen based	Jake’s cough has lasted longer than 3 weeks; productive sputum, recurrent episodes, worse with exercise, lymph nodes raised; often due to dry air in winter months in school-aged children; persistent cough irritated by nonspecific bronchial irritants; shortness of breath on exertion	No exposure to cigarette smoke in the household; Jake’s cough does not produce yellow mucus; he doesn’t have a headache, fever, chills or abdominal pain; usually more likely for chronic bronchitis to develop in adults; often cough is worse in the morning
Causal factor: Recurrent viral upper respiratory tract infections	Viruses are the most common cause of coughs in children who are in contact with other children; can exacerbate asthma symptoms	No current fever or sign of viral infection
Parasites or fungi in alveoli	Cause inflammatory cough	Rare
Enlarged adenoids	Common cause of persistent cough in children	No mention of sinus or throat concerns in the case history
STRESS AND NEUROLOGICAL DISEASE
Causal factor: Psychogenic cough	Stress at home from parents arguing	Jakes cough does not usually improve during the night or with sleep

TABLE 6.7 DECISION TABLE FOR REFERRAL [2, 5, 8, 9]

Complaint	Context	Core
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Persistent cough that is worse at night and after exercise

• Recent upper respiratory tract infection treated with antibiotics

• Possible underlying allergies or intolerances

• Lowered immunity

Nil ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE Nil

• Inadequate nutritional status (does not always eat vegetables)

• Recent use of antibiotics may have negatively affected intestinal microflora

• Tendency to anxiety

• Stress and anxiety from hearing parents arguing

REFERRAL REFERRAL REFERRAL

• Referral for medical assessment and diagnosis and management plan [70, 76]

• Dietary assessment

• Food allergy and intolerance assessment

• Massage for relaxation

• Counsellor specialising in children’s psychology to assess anxiety levels

TABLE 6.8 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1, 2, 4, 5, 10–13, 75]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Ear, nose, throat physical examination	Infection and allergic signs
Chest examination: auscultation, percussion	Signs of asthma, obstruction, infection, foreign body, heart failure
Sputum test: histology, microbiology	Detect presence of eosinophils (sign for asthma), eliminate bronchitis and pneumonia, TB, fungal origin
Lung function tests: forced expiratory volume (FEV), peak expiratory flow rate (PEF)	Will be reduced in asthma and chronic bronchitis
Exercise test	Asthma
Differential white cell count	Detection of eosinophils to confirm allergic triggers for asthma
Full blood count and IgE [74]	Infection, inflammation, anaemia, allergies
ESR/CRP	Pneumonia, infection, cancer
IF NECESSARY:
Chest x-ray	Lung abscess or tumour
Histamine/methacholine bronchial provocation test [71, 72]	Asthma
Capnometer/pulmonary gas exchange during orthostatic Tests/Nijmegen questionnaire	Hyperventilation syndrome [43–46]
Skin prick test [73]	For extrinsic allergies connected to asthma in young children
RAST [74]	To identify allergies
Food diary	To help determine any foods that may be triggering or aggravating symptoms
Sweat test	Cystic fibrosis

Confirmed diagnosis

Jake and asthma

Jake is an only child who has presented to the clinic with asthmatic symptoms following a respiratory tract infection, which was treated with antibiotics. Jake is generally a healthy and active child, although his diet appears to be lacking in a number of nutrients essential for healthy immune and lung function. Jake is also showing signs of anxiety, which may have had an effect on his immunity and respiratory health.

Asthma is a chronic inflammatory condition of the airways. Symptoms include wheezing, chest tightness, shortness of breath on expiration, a cough that is worse at night and on exertion, and production of thick clear-coloured phlegm. Onset commonly occurs in childhood and young adulthood when asthma attacks can last from hours to days. Asthma is categorised as mild, moderate or severe depending on symptom frequency and lung function tests. The condition is often initiated by a viral upper respiratory tract infection in children and may be temporary although it can often become a permanent condition. The main defining medical features of asthma include airway limitation, airway hyperresponsiveness and inflammation of the bronchi. There are both extrinsic (definite external causes such as allergies) and intrinsic (causative agents not medically identified) reasons for why asthma is triggered and develops. Precipitating factors include allergies, atmospheric and occupational pollutants [64, 65], irritants (such as cigarette smoke), medication (NSAIDs, beta-blockers), drugs, cold air, exercise, diet and emotion. Theories suggest that more exposure to allergens and illness in early years helps children boost immune response and ward off triggers for developing asthma [60, 69].

Causes of asthma include:

• elevated eosinophils in submucosa and airway exudates – these continue the inflammatory response even when the upper respiratory infection has cleared

• mucosal oedema

• production of thick mucus by airway mucosa

• increased levels of IgE – allergy.

General references used in this diagnosis: 2, 4, 10, 11, 13, 59, 61, 62, 68, 69

Prescribed medication

• Combined reliever and preventer medication

TABLE 6.9 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Lifestyle recommendations to reduce symptom severity and improve cardiopulmonary fitness • Recommendation for breathing exercises that may reduce the frequency and severity of asthma attacks • Lifestyle recommendations to identify and manage asthma triggers • Physical therapy suggestions to improve pulmonary function

• Lifestyle recommendation to reduce exposure to known and suspected environmental triggers

• Physical therapy recommendations to improve general health and immune function

• Dietary recommendations to increase consumption of foods that will improve Jake’s general health, nutrition and respiratory health

• Lifestyle recommendations to reduce Jake’s physical symptoms

• Recommendation for counselling and stress-management techniques to reduce stress and anxiety-related symptom aggravation

• Recommendation for Jake’s parents to talk to him regarding his anxieties about their arguing

• Dietary recommendations to identify and manage food allergies or sensitivities that may be triggering asthma and to increase consumption of foods with anti-inflammatory action

• Herbal tonic or tea with bronchospasmolytic, bronchodilatory, antimicrobial, expectorant anti-inflammatory and antiallergic actions

• Nutritional supplements to reduce inflammation and improve bronchial tone and lung function

NB: Herbal formula and nutritional supplements should be reviewed once Jake’s symptoms are under control; it is important for Jake’s condition to be collaboratively managed with his GP to ensure optimal treatment outcome

• Dietary recommendations to identify and manage food allergies or sensitivities

• Herbal tonic or tea with adaptogenic, antioxidant, immunomodulatory and tonic action to improve Jake’s vitality and immunity

• Supplemental nutrients to improve Jake’s levels of essential nutrients, reduce inflammation, allergic response, modulate immune function and restore intestinal microflora to improve general health and reduce asthma symptoms

NB: Supplements have been recommended in order of priority to help improve compliance and take financial considerations into account

• Recommendation to keep physically active to improve physical and emotional health

• Physical therapy suggestions to help reduce Jake’s stress and anxiety

• Herbal tonic or tea with anxiolytic and adaptogenic action to support Jake’s nervous system and stress response

• Nutritional support for stress and nervous system

Treatment aims

• Reduce inflammation [14], bronchial hyperreactivity [14] and bronchial smooth muscle contraction [15].

• Modulate immune-based inflammatory responses [14].

• Identify and eliminate or reduce exposure to allergies and/or sensitivities that are triggering Jake’s asthma [12, 15, 16, 50].

• Identify and reduce or eliminate underlying causative or sustaining factors such as:

• food allergies or intolerances [17, 50]

• compromised digestive function, hypochlorhydria [15], increased intestinal permeability [15, 51]

• underlying infection (possibly low-grade, unresolved infection) [15, 50]

• emotional stress [15]

• environmental triggers such as air pollution, cigarette smoke, cold dry air [16, 50].

• Improve Jake’s diet and nutritional status [17].

Lifestyle alterations/considerations

• Jake may benefit from controlled breathing exercises that emphasise slow regular breathing in which the ratio of inhalation to exhalation is 1:2 (e.g. yogic breathing) [16, 28]. Breathing exercises may reduce the frequency of asthma attacks [28]. Inhaling hot, moist air during breathing exercises can enhance the benefits [28].

• Encourage Jake to keep exercising as asthma symptoms are easier to control in people who are physically fit [28]. Improved cardiopulmonary fitness improves emotional status and decreases the intensity of wheezing attacks [33].

• If it is determined that Jake has environmental allergies (e.g. house dust mites, pets, etc.), it is important to manipulate his environment to reduce his exposure to environmental allergens [28].

• Encourage Jake to avoid or minimise his exposure to environmental triggers such as cold, dry air and airborne pollutants such as cigarette smoke, smoke from wood heaters, diesel fumes, etc. [16, 53, 54].

• Stress-management techniques, such as meditation, progressive muscle relaxation and autogenic training, can help manage stress and improve pulmonary function [28]. There is considerable evidence for a link between emotional or stress responses and asthma [32]. Helping Jake to cope with his stress and emotions may help improve his asthma symptoms [32].

• Jake needs to get an asthma-management plan from his doctor. Asthma-management plans are designed to help children and parents identify early signs of worsening asthma and intervene early with appropriate treatment strategies to prevent symptoms worsening. Written asthma-management plans are strongly associated with a reduced risk of adverse outcomes among children with asthma [34].

• Jake may benefit from counselling to help him learn helpful coping strategies to deal with his anxiety [35].

• Encourage Jake’s parents to talk to him about his anxieties, particularly relating to him overhearing them arguing. Reassurance from his parents is important.

Dietary suggestions

For compliance reasons, these are listed in order of priority. Jake may not be happy with an immediate radical change to his diet. The authors’ clinical experience has shown that gradual dietary change is more likely to be permanent than immediate radical dietary change.

• Jake should increase dietary intake of omega-3 fatty acids from cold-water fish, almonds, walnuts, pumpkin and flaxseed [28, 47] and reduce omega-6 [48] and trans-fatty acids [49]. Consumption of fresh oily fish is associated with a significantly reduced risk of asthma and improved pulmonary function [28, 47].

• Check for food sensitivities, intolerances or allergies and avoid foods that may precipitate an asthma attack [12, 15–17]. Some asthmatics experience significant improvement when excluding known reactive foods [17]. Foods most commonly found to be reactive include eggs, dairy food, wheat, fish, citrus fruits, peanuts and soya [17].

• Avoid exposure to food additives [16, 55, 56].

• Encourage Jake to consume more antioxidant-containing whole foods (vegetables, fruit, whole grains, legumes, etc.) [15, 17] and reduce consumption of refined carbohydrates and sugar. Jake needs to increase his intake of essential nutrients [17].

• Include onions and garlic in Jake’s diet. Compounds found in onions reduce leukotriene synthesis and can reduce bronchoconstriction [28].

• Avoid excessive salt intake; it may increase bronchial reactivity [14].

Physical treatment suggestions

• Acupuncture may improve Jake’s quality of life and reduce his need for bronchodilator medication [25, 37]. When combined with conventional treatment, acupuncture performed in accordance with traditional Chinese medicine principles has significant immune modulating effects [26].

• Massage therapy may be beneficial to Jake. It may help to improved his pulmonary function [27, 36] and massage may help reduce his stress and anxiety [36].

• Hydrotherapy: constitutional hydrotherapy [38–40]. Back and front contrast treatment with cold mitten friction on the trunk when symptoms begin to ease [40, 41]. A hot chest shower [41]. Smear a mustard plaster on the chest consisting of one part mustard powder to three parts flour with enough water to make a paste [42]. A steam vapouriser will assist breathing [42].

TABLE 6.10 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

Made with ethanolic extract herbal liquids (alcohol removed)
HERB	FORMULA	RATIONALE
Ginkgo Ginkgo biloba 50:1 Standardised extract equivalent to 4–8 g leaf [18]	40 mL	Anti-PAF activity [18]; antioxidant [18, 19]; immunostimulant [19]; anti-inflammatory [19]; anxiolytic [19]; reduces airway hyperreactivity [19]; protective against exercise induced bronchospasm [20]
Euphorbia Euphorbia hirta

10 mL Expectorant [23, 24]; anti-asthmatic [23, 24]; traditionally used for bronchial asthma [23, 24]

Adhatoda

Adhatoda vasica

40 mL Expectorant [21]; bronchodilator [21]; anti-asthmatic [21]; protects against histamine induced bronchospasm [21]; traditionally used to treat bronchitis and asthma [22] and considered to be a sedative expectorant [22]

Baical scullcap

Scutellaria baicalensis

80 mL Antiallergic [19, 21]; antioxidant [19]; anti-inflammatory [19, 21]; antimicrobial [19, 21]; anxiolytic [19]

Licorice

Glycyrrhiza glabra

30 mL Expectorant [18, 19]; antitussive [19]; antoixidant [19]; anti-inflammatory [18, 19]; antibacterial [18, 19]; immunomodulator [19]; adaptogen [18, 19]; adrenal tonic [18, 19]; also useful to include in Jake’s formula to help improve the taste Supply: 200 mL Dose: 5 mL twice daily

TABLE 6.11 HERBAL TEA

Alternative to herbal tonic if a tea improves compliance
HERB	FORMULA	RATIONALE
Licorice root Glycyrrhiza glabra	2 parts	See above
Thyme leaf Thymus vulgarus	2 parts	Antispasmodic [18, 19]; antimicrobial [18, 19]; expectorant [18]; antitussive [19]; anti-inflammatory [19]; antioxidant [19]; traditionally used in bronchitis and asthma and upper respiratory tract inflammation [18]; approved by Commission E for the treatment of bronchitis, whooping cough and upper respiratory tract catarrh [19]
Fennel seed Foeniculum officinale	½ part	Spasmolytic [18, 23]; antimicrobial [18, 23]; expectorant [18, 23]; traditional European use for upper respiratory tract conditions in children [23]
Grindelia Grindelia camporum	1 part	Expectorant [23, 24]; antispasmodic [23, 24]; bronchospasmolytic [23]; traditionally used for asthma, bronchitis and whooping cough [23]; BHP indication to combine with licorice in asthma and bronchitis [24]

Decoction: 1 tsp per cup – 1 cup twice daily

Nutritional supplements

Listed in order of priority. Jake’s parents may only want to take one or two supplements initially due to financial reasons, or because of concerns regarding compliance.

TABLE 6.12

SUPPLEMENT AND DOSE	RATIONALE
Omega-3 fish oil 3000 mg daily in divided doses [14, 19]	Anti-inflammatory [14, 16, 19]; when taken in combination with dietary changes, improvements in asthma symptoms and lung function measurements are seen [19]
High-potency practitioner-strength probiotic supplement containing Lactobacillus GG [52] Dosage as directed by the manufacturer for a child of Jake’s age and weight

Immune system modulator [19, 37, 52]; immune stimulant [19]; important for the development and maintenance of a healthy immune system [19] and supplementation may be beneficial in atopic conditions [51]; may help prevent disruption to intestinal microflora following antibiotic therapy [31]

Vitamin C

Approx. 1500 mg daily in divided doses [14, 16]

Protects against exercise induced asthma [14, 16]; antioxidant [14, 19]; immunostimulant [14, 19]; antihistamine [19] Magnesium citrate supplement providing a daily dose of 290 mg elemental magnesium [19] Influences bronchial vasomotor tone and pulmonary vascular muscle contractility [19]; magnesium supplementation can improve asthma symptoms in children [19, 29, 57] [58], reduce bronchial reactivity [29] and reduce bronchodilator use [58]

References

[1] Douglas G., Nicol F., Robertson C. Macleod’s Clinical Examination, twelfth edn. Churchill Livingstone Elsevier; 2009.

[2] Kumar P., Clark C. Clinical Medicine, sixth edn. London: Elsevier Saunders; 2005.

[3] Talley N.J., O’Connor S. Pocket Clinical Examination, third edn. Australia: Churchill Livingstone Elsevier; 2009.

[4] Polmear A., ed. Evidence-Based Diagnosis in Primary Care. Churchill Livingstone Elsevier, Edinburgh, 2008.

[5] Collins R.D. Differential Diagnosis in Primary Care, fourth edn. Philadelphia: Lippincott Williams & Wilkins; 2008.

[6] Silverman J., Kurtz S., Draper J. Skills for Communicating with Patients, second edn. Oxford: Radcliff Publishing; 2000.

[7] Neighbour R. The Inner Consultation; how to develop an effective and intuitive consulting style. Oxon: Radcliff Publishing; 2005.

[8] Peters D., Chaitow L., Harris G., Morrison S. Integrating Complementary Therapies in Primary Care. London: Churchill Livingstone; 2002.

[9] Lloyd M., Bor R. Communication Skills For Medicine, third edn. Edinburgh: Churchill Livingstone Elsevier; 2009.

[10] Seller R.H. Differential Diagnosis of Common Complaints, fifth edn. Philadelphia: Saunders Elsevier; 2007.

[11] Jamison J. Differential Diagnosis for Primary Care, second edn. London: Churchill Livingstone Elsevier; 2006.