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GUIDELINES FOR COMPREHENSIVE HOMEOPATHIC CASE-TAKING IN PNEUMONIA AND/OR PLEURISY A questionnaire for Case-taking in pneumonia and/or pleurisy Case History Physical Examination Further Hints on homeopathic Diagnostics Auscultation Respiratory rate Chest-Percussion Vocal Fremitus Pulse and Temperature Peripheral Blood Oxygenisation X-Ray Examination Blood-Examination GUIDELINES FOR COMPREHENSIVE HOMEOPATHIC CASE-TAKING IN PNEUMONIA AND/OR PLEURISY A questionnaire for Case-taking in pneumonia and/or pleurisy NOTE - This questionnaire should only be used as a guideline to help gather as many important and helpful aspects/symptoms/dynamics of the case, and especially of the current state of the patient, as possible, in order to develop "the true picture" of the sick individual person at that specific moment! The challenge and art of case-taking at this point is to collect all the valuable information on the case on the one hand and on the other hand not to distort the picture by adding (general-)symptoms, which would be irrelevant at the given moment. Mind what information you combine to form the characteristic disease-picture, to which you want to find a corresponding remedy! There might be only 1-3 characteristic features, yet there also might be many more. It may be helpful to look through the corresponding chapters of the repertory regarding each hint and the materia medica to obtain ideas of what could be useful information - also to be able to match so called "small" and "big" remedies to a given case. Case History Let the patient spontaneously and personally describe the disease and its symptoms - without interruption by the homeopath! Let the patient add any additional information, if not already given in the spontaneous report. (Gather the localization, character, modalities, and concomitants of all symptoms as comprehensively as possible!) > Precise begin and development of symptoms (when, how: suddenly or slowly) o Possible causations - such as cold wind, wet weather, dust, shocks, grief, etc. o Esp. in children the observations of the parents are very relevant o Consider the possibility of certifiable diseases! If pneumonia is suspected, a thorough case-history including the possible causation is important, because a certifiable disease may be the cause (e.g. measles, legionnaires disease, etc.)! - Current stage of the disease [very important in lobar pneumonia! glt2] (First, second, third, neglected) [very important!, see e.g. Nash nh6, or Raue rec1,] snex Mind: Not all remedies - esp. "smaller remedies in pneumonia" already have clear annotations in what stage they might be useful. So if you find remedies fitting the characteristics of the case, rank these higher than the ones fitting a certain stage of the disease! - Other acute diseases relevant for the case (e.g. Influenza, measles, whooping cough, etc. - which might have been suppressed) - Chronic diseases relevant for the case (heart-, kidney-insufficiency, COPD, alcoholism, atopic eczema, asthma, etc.) - Chronic medication (esp. potentially suppressing ones - e.g. corticoid-ointments for atopic eczema, other immunosuppressants, etc. ) - Age - esp. infants or old people - Possible causations/triggers of the pneumonia/pleurisy (e.g. surgery, loss of fluid, weather, air, emotions, suppression of eruptions, etc.) [Useful for remedy-selection only in the first phase of the disease! glt2] - Treatment of the acute case so far (esp. Antibiotics, Antipyretics, Cortisol) - Understanding of the disease-process, the circumstances, and exact course of symptom-development (past history) Mind esp. state of consciousness (clear, typhoid, delirious, sleepy, etc.); sense of orientation Mood snex, delusions, dreams, fears, relationship to and behavior toward care-takers Behavioral symptoms (if strong) Head esp. headache with modalities Eyes pupils (dilated, contracted), inflammation, photophobia, etc. Nose sneezing, nose-bleeding, motion of alae nasi Smelling alterations Mouth changes of taste Face esp. subjective temperature; sordes, swelling, expression glt2, colour, frowning, open mouth, herpetic eruptions Throat Stomach esp. appetite, thirst snex, nausea, vomiting Abdomen esp. abdominal distension, resistency (liver), colour, temperature Stool esp. diarrhea, constipation, colour, texture, smell, acrid Urine colour, sediment, smell, temperature, (see footnote by Royal) Larynx and trachea esp. pain or changes of speech Respiration what kind (e.g. wheezing, rattling, etc.), modalities glt2 Cough what kind (dry, loose, hacking, tickling), excited by which conditions, concomitant symptoms glt2 Expectoration times/frequency, under what conditions, taste Sputum colour, texture, smell, taste Chest esp. pain, incl. conditions snex (esp. most comfortable position for the patient!) Heart and blood vessels esp. palpitations Back esp. extending pains Extremities Sleep esp. position taken, sleeplessness, yawning, was sleep recreative or not Chill location, extension, reaction to covering up, other modalities Fever see Repertory for relevant characteristics Perspiration times, modalities, at what stages, location glt2 Skin pain, itching, eruptions (suppressed), etc. Generals general modalities, faintness, food (desires, aversions, aggravations), weakness, job (stone-cutter, baker, brainworker, etc.) constitution, convulsions, general qualities of pain, etc. Physical Examination State of consciousness (clear, typhoid, delirious, stuporous, etc.) In typhoid or delirious states - signs that can be observed (e.g. picking at clothes, restlessness, etc.) Signs of biliary complications? (skin, yellow conjunctivae, liver enlarged or painful, etc.) Position taken by the patient (esp. in infants - back, side, position of the head, etc.) Skin (head to toes!) - colour, dry, wet, warm, cold, - which parts affected Eyes - esp. pupils (dilated, contracted, distorted), injection, lids open, half-open, swollen, etc. Nose - esp. colour, motion of alae nasi (not (very) specific in nurslings but very specific the older the patient! Ed.) Mouth - Tongue bl4 - dry/moist (with or without thirst), colour, coating, swelling taste smell Face - colour, expression, temperature, motion (twitching, etc.) Facial expression indicating acute respiratory distress-syndrome glt2,2023 Widely opened eyes (Eyes/Lids/Open) Highly raised eyebrows (Face/Wrinkled) Empty vision Tensed upper lip Atonic jaw (mouth slightly opened, chin pushed forward) Alae nasi tensed Expressionless face Cyanosis of lips - in children - usually dark red colour - blueness only shortly before coma Straining on inspiration (in nurslings under these conditions 60-70% of their energy is needed for breathing). In later phase (shortly before suffocation): Eyebrows drawn together Face stiff around the eyes Maximum opening of alae nasi and mouth (Nose/Motion of wings, fan-like) For Auscultation a) Lungs - location of the disease (esp. when middle or upper lobe is involved) [60% right lower lobe, 24% left lower lobe, followed by right middle lobe and then upper right and left lobe glt2] Auscultation sounds (wheezing, rattling, etc.) - Breathing mechanics (spasmodic strictures, position of head - Breathing frequency and form b) Pleura - involved? c) Heart - heart sounds, d) Abdomen - peristalsis (if higher risk of ileus!) Respiratory rate (references see below) Expectoration - colour, texture, amount, smell, times/frequency, difficulty ito expectorate Abdominal palpation - painful abdomen indicates danger of ileus! Pulse - see Repertory Anus - esp. hemorrhoids, excoriations caused by stool, ... Stool - colour, texture, smell, acrid? Urine - colour, sediment, smell, temperature, (see footnote by Royal) SO2-Measurement - see below Habitus of the patient (color, expression, general condition, etc.) Further Hints on homeopathic Diagnostics Rabe rbbx,1918: To prescribe successfully for the pneumonia patient requires that the physician sits down quietly at the bedside and calmly contemplate the case from every side and angle. We homeopaths are compelled to treat patients, not diseases and the recognition of the symptom image is by no means always easy. He who is not dominated in his actions by law and principle is likely to be easily stampeded, so that his therapeutics become a jumble of unrelated and antagonistic remedial measures. Blackwood bwax,1902: Acute pneumonia in the aged and those with great lowering of the nervous vitality is often mistaken for typhoid fever, as the cough, expectoration, pain, and in some cases the dyspnea, may all be absent. In these cases the physical examination of the lungs must be relied upon. In the alcoholic, the symptoms of pneumonia may simulate those of delirium tremens and in such cases a careful physical examination is also demanded. Saine snex,2023: Patients with pneumonia have a lot of objective and subjective symptoms (which you can repertorize): - e.g. headaches, chest pain So a lot of modalities concerning the headaches, chills and modalities of the chills, fever, pulse, disposition, mood. E.g. Carb-v. is irritable (?) and apathetic, careless. Ant-t. does not want to be touched or looked at, thirst and appetite are important. (No appetite is not peculiar). But if they say they want to drink lemonade with pneumonia -> could (probably) be Bell.; chest pain and modalities: how is this pain with breathing, with different positions; shortness of breath and modalities: e.g. what positions are better and worse; cough, sputum; urination; warm or chilly; window open or closed, etc. So it is hard not to get a remedy picture! Clinical experience Galic glt2.2023: In pneumonia-cases the therapeutic window is narrow - this means that the remedy has to fit very accurately for a curative reaction. Symptoms which arise when the patient's consciousness decreases can individualize the clinical state. In patients (esp. children) who have been treated with e.g. antibiotics for tonsillitis or immunosuppressive ointments for eczema, a severe course of the disease is likely. In that case symptoms of the past history are a must-have for case-analysis. If the patient has a past history of spasmodic cough (esp. whooping cough) those symptoms can be valuable for differentiating remedies - even if the current symptoms are different! If symptoms of behavior come forward strongly, they indicate differentiating symptoms regarding the quality of the patient's overall condition. Acute symptoms of mental health can show up unexpectedly and without apparent reasons or causes. (Therefore they can be difficult to understand for observers - esp. for parents). It is very important to always separate phenomena of behavior (esp. of children) from the interpretations made by parents during case-taking! Esp. regarding broncho-pneumonia in children: Often you find an unclear state of the patient. If you focus on the exact phenomena of the case, several remedies can be substantiated. During the treatment a certain crisis is probable, with escalation of fever, low to high degree of lung-infiltration, drastically reduced general condition. The successful management of the acute crisis often improves the entire case. The symptom-patterns of the indicated remedies often do not present themselves with expected and known common symptoms. Often you will find symptoms of remedies such as Medorrhinum, Thuja, Pulsatilla, etc. without typical keynotes of these remedies. Auscultation glt1,2023 Auscultation is the most important physical examination method for breathing disorders. In most cases pneumonia can be detected by auscultation if the examiner has appropriate experience! [Yet there are some cases where only X-ray shows the infiltrate. Ed.] Auscultation in Adults: It is important to do auscultation in anterior, posterior axillary line and in the medio-scapular line - in order to receive an overview of the diagnostic findings as exactly as possible. Consider that by auscultation you can only examine the outer parts of the lungs with max. 4-5 cm skin depth. Personal clinical Hint glt2: To detect central infiltration you can try to auscultate indirect sounds in front of the mouth. For this the stethoscope-membrane is held parallel to the airflow next to the mouth. During forced maximum expiration crepitation can be heard at the end of expiration, which can not be heard on auscultation of the thorax. [In case of doubt for central pneumonia x-ray examination can help! Ed.] Assessment of Lung-Auscultation Sounds Frequency (see below) Sound intensity Distribution of inspiration and expiration lengths Vesicular breathing is louder and longer on expiration. Bronchial breathing is louder and sharper on inspiration Assessment of accompanying Sounds Continuity of the sound - Is it always the same sound, always at the same spot? Stridor in children is often loud and therefore hard to localize The earlier in the breathing cycle it can be heard the higher the breathing-obstacle lies e.g. tsridor at the beginning of inhaling indicates a blockage in the upper airways (larynx,) stridor towards the end of exhaling indicates a blockage in the terminal bronchi. Crepitation is conclusive evidence that there is interstitial fluid and a sure sign of pneumonia. Rattling sounds can be fine or rough. Frequent Mistakes in Auscultation Stethoscope is not in close contact with the skin surface or twisted. Chest hair produces false sounds on movement of the membrane. Sounds from touching the tube of the stethoscope. Specifications for Children All important auscultation-spots should be examined with child undressed! Thorough and repeated auscultation, esp. in axilla, scapular-region and under clavicles is essential. Children older than one year can be examined while sitting, anxious children can sit on the parent's arm. Caution: Pneumonia in children is most frequently in the right side of the lung - and the lower lobe on that side can only be auscultated on the side or on the back! In central pneumonia no sounds can be heard on the surface of the lungs! Sometimes a slight "chimney drought noise" sound can be heard or nothing at all. Pulmonary mobility in children is 1-2 fingers on the front side:; 3-4 fingers on the back side. As soon as breathing sounds at the base of the lungs are as loud as at the apex of the lungs, this is a first sign of pneumonia (often 1-2 days ahead of other signs)! Auscultation-results of the left upper lobe are best examined in the axilla because heart-sounds are weaker there! And remember: A child that cries continuously during examination and tries to stop examination hardly suffers from pneumonia. Breathing dynamics in Children Nurslings use abdominal breathing. From the age of two there is an increase of chest breathing. In infants the ratio is approximately 1/3 chest breathing and 2/3 abdominal breathing. Undulating breathing volumes (similar to Cheyne-Stokes-breathing but without longer breathing pauses) are regular in newborns and very frequently in infants - until the end of the first year of life this is physiological! Tips for Auscultation of Nurslings They should be auscultated lying on the back AND lying on the abdomen. Also try to hold the membrane of the stethoscope to the child's mouth. Editors: Auscultation is a practical skill, which cannot be taught comprehensively by a textbook. It needs a lot of training to be done correctly and to be able to recognize and differentiate the sounds heard in correspondence with other clinical findings. We consider live teaching with real patients to be the best way to learn auscultation. Listening comprehensions offer some help and various sources can be found on audio CD or online. In order to gain understanding of which sounds are helpful for homeopathic prescribing, you may check the repertory chapter on respiration. Respiratory rate Saine: snex,2023 This is also a very important feature.
The breathing rate in the first year of life shows the greatest variability of 20-45/min (average of 30/min). This decreases till the third year of life to 20-25/min and then continually till adulthood to 15/min on average. In infants 30/min is normal. 80/min is very high. But in adults 30/min is high, 45/min is very high. Any variation of these could mean that the condition is getting better or worse. Chest-Percussion Percussion only provides accurate results regarding the differentiation the organs and their borders as of the age by which children are able to breathe in and out and hold their breath cooperatively. Vocal Fremitus By examining the vocal fremitus via palpation you can ascertain signs indicated by your preceding inspection and assessment of the state of the pleura and lung parenchyma. Vocal (tactile) fremitus is performed by palpating the chest wall and back to detect changes in the intensity of vibrations created with certain spoken words with long tones indicating underlying lung pathology. For this examination the patient says words with deep-tone vowels in a low voice such as "ninetynine" while the physician places his hands on the chest and back. Vocal fremitus is decreased in bronchial asthma, emphysema, atelectasis, pleural thickening or bronchial obstruction due to air trapping and decreased density of lung parenchyma. In case of pleural effusion and pneumothorax, air/fluid accumulates in the potential space between the chest wall and lung parenchyma, decreasing the transmission of lower frequency sound vibrations. Vocal fremitus also may be decreased in individuals with obesity. Contrary to these findings, inflammation and consolidation create a dense medium which increases the transmission of lower frequency sounds and vocal fremitus. Vocal resonance is the auscultatory counterpart to vocal fremitus. The following changes in vocal resonance can be observed. Bronchophony: A louder sound heard over an area of consolidation. Whispered Pectoriloquy: While the examiner auscultates over the lung fields, the patient is asked to whisper "one, two, three." Whispered words are heard clearly in case of consolidation. Whispered pectoriloquy has the same significance as increased fremitus and does not deliver any new information. Egophony or an "E to A" Change: A qualitative change in the voice that resembles the bleating of a goat. Selected sound frequencies are able to pass through consolidation and tend to distort the sound of the vowel "E" so that it is perceived by the examiner as "A" or "AAAH." (Source - Pranav, Modi et al. Vocal fremitus, StatPearls. Treasure Island (FL): StatPearls Publishing; 2022 Jan.) Practical advice glt2: Vocal fremitus and bronchophonia are not necessarily very helpful examinations in practice. Firstly they are imprecise and secondly they can only be determined to a certain limited extent. Sick children seldomly participate in the examination and in adults it only works if the person is quite slim. Pulse and Temperature snex,2023 Saine: snex,2023 They are both very important for homeopathic case-taking and case management. Pulse It is the most sensitive parameter. It has to be taken when the person is at rest (means he/she should lie calmly 5 minutes before taking the pulse and at specific times of the day, e.g. first thing in the morning, or at noon. Pulse frequency; Average (statistical values):
Pulsus paradoxus gltx,2023: Sudden decrease of pulse-rate and blood-pressure on inhalation (>10mmHg). This occurs when the lungs are over-inflated, which again effects the heart to the extent that it cannot fill up as well and therefore pulse and blood pressure decrease. A characteristic sign of hyperinflation of the lungs is marked fluctuation of pulse-frequency between inhalation and exhalation! Causes can be massive obstruction (e.g. in severe asthmatic attacks with hyperinflation, pericardial effusion with danger of tamponade, and tension pneumothorax.) Under normal conditions blood-pressure is held stable during inspiration due to a slight increase of the pulse-rate. If this compensation is impossible due to compression of the left ventricle, this ventricle fills up insufficiently during inspiration, so that both pulse and blood-pressure drop. On expiration this process is reversed. Mills milx,1915: After the crisis (Ed. - in lobar pneumonia) a slow pulse is normal. Nothing should be done to accelerate it. Nature is conserving the heart muscle. A quick pulse, after the crisis, means an irritable heart, that must be corrected by continued rest. Body-Temperature 20 The rectal temperature measurement is the most accurate and takes approximately 1 minute. It is definitely the method of choice for examining babies under one year of age. Infrared ear thermometers are often used as a faster method. However, this measurement is less reliable than rectal measurement (average temperature difference 0.4 degrees). Rectal measurement: daily rhythmic fluctuations of 0.5 - 1°C around 37°C. Max. 37.3°C in the morning and 37.8°C in the evening. Axillary measurement: max. 36.8°C, duration approx. 5 min. Sublingual measurement: max. 37.0°C, duration approx. 5 min. In women, the body temperature depends on the progesterone-estrogen ratio. About 24 hours after ovulation, in the 2nd half of the cycle, the temperature rises by about 0.5°C on average. Measurements of up to 38.2°C rectally are known as subfebrile temperatures. As of 38.2°C measured rectally the patient has fever. The fever is usually higher in the evening than in the morning Types of Fever Febris continua: fever lasting >3 days with a relatively constant temperature increase >39°C and daily fluctuations of <1°C Febris remittens: minimum temperature > normal value, temperature fluctuations >1°C Febris intermittens: minimum temperature = normal value, daily fluctuations =1°C Febris recurrens: periodic fever progression with fever-free intervals Febris undulans: Fever with prolonged temperature increases, possibly lasting weeks, in the form of a gradual rise and fall with intermittent fever-free periods Peripheral Blood Oxygenisation EMB ebm1,2015 Measurement of peripheral oxygen saturation: - Is a good tool to detect hypoxemia, but does not detect hypoventilation - The individual goal of treatment must be adapted to the patient and the situation - Normally, values >90% are sufficient. In acute situations values of 94-98% saturation should be aimed for, unless the patient is prone to CO2 retention - Caution: Even if peripheral oxygen saturation is >90%, severe hypoventilation may be present with high arterial CO2 Range 95-100% - Normal 91-95% - Cause of concern. Intensive (home-)care and observation needed. <91% - Medical emergency - Administration to hospital if possible! 80-85% - Beginning damage to the brain <67% - Central Cyanosis Further important features for oxigenisation measurement - Use only medically calibrated high-quality pulse oximeters - Calibration of the pulse oximeter should be done at least annually - Cold fingers show oxygenisation-measurements too low - The sensor has to fit the finger exactly to give real data. There are special sensors for every age/size of finger - Any reduction in blood-circulation especially in the arm where the oximeter is set, gives lower measurements - Superficial breathing gives lower measurements - Fingernails should not be painted X-Ray Examination Clinical examination with percussion, auscultation, fremitus, etc. are excellent tools for diagnosing pneumonia and/or pleurisy. Still these examination methods have their limits. One limitation is possible lack of training, experience and skill of the examiner. Second, every examination has its limitation range. Auscultation usually only provides detectable sounds from 4-5cm below the skin surface. This indicates that central pneumonia often cannot be detected by auscultation and needs x-ray for exact diagnosis. Therefore, in case of doubt, an x-ray should be taken. At the same time even x-ray-examination does not always show an infiltrate in a case of pneumonia. In these cases the clinical impression gives the lead. X-ray-examination in lying patients does not rule out pneumonia. Guidelines recommend to do x-rays with patients standing and taking pictures from the front and from the side. In cause of doubt due to a clinically unremarkable x-ray, a CT-scan is indicated, especially if hypoxemia is present. A further diagnostic possibility is ultrasound-examination, which affords an experienced examiner. For differential diagnosis between lobar pneumonia, tuberculous pneumonia and bronchial cancer with atelectasis, chest-x-rays often offer the best results. Saine snex: I do not use x-ray too much. Do a good auscultation and percussion and look for fremitus. Blood-Examination EMB ebm1,2015 CRP and leukocyte count reveal more regarding the extent of tissue damage than regarding the causative pathogen. However, a CRP value > 80 mg/l usually indicates a bacterial infection and a very high CRP indicates a pneumococcal infection. When interpreting the CRP value, however, one should forget that pneumococcal pneumonia can develop very quickly, and that the CRP may therefore not be elevated at the very beginning of the disease. (Procalcitonin (PCT) has a higher specificity and sensitivity to indicate bacterial inflammation). In patients with poor general condition serum potassium, sodium, creatinine, and arterial blood gas levels should be determined. If Legionellosis or chlamydial infection (atypical pneumonia) is suspected, serum transaminases and alkaline phosphatase should also be determined. In primary care, clarification of the pathogen is not necessary. Two samples for blood cultures should be taken from patients with poor general condition. For differential diagnosis urine culture, blood glucose determination, and ECG may be necessary. [Even with extensive microbiological diagnostics, however, pathogen detection is only successful in 30-50% of the cases. kroe1,2014] Galic glt1,2023: A missing Leukocytosis is a warning sign for a life-threatening case with severe infection and weakened reactivity of the patient. After the crisis you often find a hypo-chromatic anemia like in all types of septic fever. Annotation by the Editors according Training of physical Examination With access to the world-wide-web it can be valuable to watch tutorials on state-of-the-art physical examination, in case you feel insecure about proper clinical examination. These can be found on various sites in different languages. We recommend to refer to homepages of high standard medical educational institutes, such as the University of Bern (Switzerland) or the Oxford Medical Education Center. ◄ ANATOMICAL AND PHYSIOLOGICAL SPECIFICATIONS IN CHILDREN | ▲ | CASE MANAGEMENT ► |