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Creating Waves of Awareness

The determination of what is wrong with a patient is called a diagnosis. Any disruption of normal body function is regarded as a disease. Structural changes associated with a disease are called lesions. Diseases may be classified into two broad categories:
• Organic: disease that has identifiable lesions.
• Functional: disease with no lesions.
The term pathology refers to the study of disease. A pathologist specializes in the diagnosis and classification of diseases. Etiology is the study of the causes of disease. Pathogenesis refers to how a disease progresses and develops. A pathogen is something that causes disease such as a virus or bacteria.
Diseases are often classified into the following general categories based on lesions or pathogenesis:
• Congenital & hereditary - results from developmental disturbances and may be genetic, intrauterine injuries, or a combination of these factors.
• Inflammatory - results from reaction to injurious agent, such as bacteria or virus, by inflammation or, may result from antibodies against own tissues (autoimmune disease).
• De-generative - results from degeneration of tissues of the body. Examples include aging, arthritis, atherosclerosis.
• Metabolic - results from a disturbance of a metabolic process in the body. Examples include, diabetes, hypothyroidism, various hormonal disorders, and electrolyte imbalances.
• Neoplastic - results from abnormal cell growth and leads to formation of benign or malignant tumors.
Subjective symptoms of a disease are described as symptoms. They are what is reported to the clinician by the patient, for example, "I feel... hot, nauseated, pain, dizzy", etc. Objective findings by the clinician are termed signs. They are measurable findings such as temperature, blood pressure, posture, gait, behavior, and appearance. Once a diagnosis is made, a prognosis may be given which is a prediction of the eventual outcome of the disease. It may be given as excellent, good, fair, poor, or sometimes as a percentage based on research statistics.

.GENERAL: appropriate to stated age, sex and gender, changes in health lifestyle, appetite, chills, night seats or weight, leathery, malaise, fatigue.
.SKIN: rashes, pruritis, jaundice, bruising, skin cancer, mole changes, changes in hair or nails or lesions, skin is intake and heals well.
.HEAD: trauma, lumps, masses, tenderness, dizziness, H/A, syncope or seizures, face or scalp rashes.
.EYES: photophobia, visual field changes, blurring, star burs, diplopia, spots, itching, discharge, excessive tearing, dry eyes, cataracts, glaucoma, current vision/uncorrected corrected? /last eye exam/vision is? In R/L/both eyes with contact lenses or glasses?
.EARS: hearing changes, tinnitus, pain, discharge, vertigo, OM? Hearing.
.NOSE: discomfort, nosebleeds, frequent colds, nasal stuffiness, discharge, itching, hay fever, or sinus troubles.
.MOUTH & THROAT: gum bleeding or swelling, oral pain, frequent sore throat, vocal changes or tooth loss, last dental exam.
.NECK: pain, discomfort, lumps/swelling, diff. Swallowing or moving neck.
.BREAST: lumps, pain, or nipple discharge, last breast exam, last mammogram, findings on self-breast exams?
.RESPIRATORY: wheezing, dyspnea, coughing, hemoptosis, asthma, TB, bronchitis, pneumonia, emphysema or shortness of breath, last CXR?
.CARDIAC: chest pain, dizziness, orthopnea, edema, palpitations, weakness on exertion, known heart murmurs, HTN, last ECG.
.CIRCULATORY: numbness, tingling, cold extremities, edema, wound healing.
.LYMPHATICS: adenopathy, recurrent neck, axillary or groin tenderness.
.GASTROINTESTINAL: abdominal pain, change in bowel habits, jaundice, hepatitis, gallstones, dysphagia, adynophagia, heartburn, hemorrhoids, tenesmus, constipation, diarrhea, nausea or vomiting, appetite, last BM frequency, frank blood/tarry stools.
.URINARY: burning or pain upon urination, nocturia, polyuria, hematuria, incontinence, infections and kidney stones.
.GENITAL: discharge, sores, pain or masses, Hx STDs.
.GYNECOLOGICAL: age of menarche, regularity of menses, G0P000,(See OB pg. For G/P status), sexually at? # Partners. Last OB/GYN/PAP smear -/+. Gynecological or surgical procedures.
.MUSCULOSKELETAL: redness, swelling, warmth, pain, discomfort, ROM.
.NEUROLOGICAL: neurological deficit, vertigo, syncope, seizure activity, motor/sensory deficit, memory loss, LOC, gait change, speech and coordination.
.ENDOCRINE: polydypsia, polyuria, polyphagia, temperature intolerance, glycosuria, hormone therapy, changes in hair, energy levels, sweat, skin.
.HEMATOLOGICAL: anemia, bleeding tendency, easy bruising, lymphadenopathy, transfusions and blood disorders.
.PSYCHOLOGICAL: suicidal or homicidal ideation, depression, anxiety, phobias and changes in sleep patterns, drug or alcohol abuse, memory loss.
.GENERAL SURVEY: appearance/health, nourishment, grooming, posture & gait? Affect (explain: smiling, apathetic, etc.), CAO X 4, speech, motor activity tremor or shake, signs of distress.
.SKIN: color, temp, moisture, cyanosis, mottling, same temperature, peripherally to centrally, hair distribution, texture and turgor, jaundice, clubbing, capillary refill, nail beds, buccal/conjunctival mucous membrane.
.HEAD: shape, trauma?, pain on palpation, signs of injury or deformity, masses, nodules, tenderness, hair texture, distribution, hygiene, lesions of scalp, psoriasis, nits, lice, face symmetry, paralysis? skin problems?
.EYES: conjunctiva, lid lag, strabismus, exophthalmos, PERRLA, nystagmus, EOM, visual acuity, corneas clear? Fundoscopy: red reflex, retina, AV nicking, exudates, papilledema, lacrimal apparatus tenderness or exudate.
.EARS: tragal palpation, deformity/pain to pinna, mastoid percussion, visible discharge, swelling. Otoscopic exam: external redness or edema, cerumen, light reflex, indurated, retracted, injected, perforations, hearing.
.NOSE and SINUSES: deformity, patency, smell, pain, discoloration, swelling, septum midline, inferior and middle turbinates, ulcerations or polyps, frontal and maxillary sinus pain.
.MOUTH: Inspection: lips, teeth, gums, deformity, lesions, ulcers. Buccal mucosa: lesions, sores, color. Teeth: present? Tartar, caries, gingivitis? Soft and hard palate: symmetrical? Tongue: exudate, lesions, tongue midline, gag reflex, palatine rise, phonation deficit,. Soft palate: uvula, tonsils and oral pharynx exudates, parotid and submandibular glands pain or enlargement, Stensen's and Wharton's ducts abscess or stricture.
.NECK: deformity, trachea midline, pre auricular, post auricular, occipital, posterior cervical, superficial cervical, deep cervical, tonsilar, submandib, sub mental and supraclavicular lymph nodes tender? supple, ROM? Thyroid gland palpable/tender/goiter, diff. swallowing, carotid bruits, JVD.
.LUNGS and THORAX: symmetrical chest rise, signs of distress, retractions, accessory muscle use, AP diameter, deformities or pain, expansion, Percussion, diaphragmatic excursion, Auscultation, Tactile fremitus, egophony, bronchophony.
.BREAST: pain, discoloration, symmetrical, dimpling, tenderness, retractions, masses, "orange peel"
.CARDIOVASCULAR: extremities temperature & moisture, radial, ulnar, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis pulses +2? Sacral, pedal or other dependant edema, measure JVP, lifts or heaves. Palpation of aortic, pulmonic, left sternal border, tricuspid and mitral areas for lifts, heaves or thrills, PMI displaced? location? Auscultation of rate, S1 and S2, S3, S4, bruits, murmurs? Murmurs with patient L lateral, decubitus or sitting up or leaning forward.
.ABDOMEN: contour, lesions, striae, spider veins, visible peristalsis. Bowel sounds. Bruits in aortic, renal, iliac, femoral. Percussion: liver span, splenic percussion. Light/deep palpation, liver palpable, spleen or kidneys palpable, CVA percussion. Rovsing's, McBurny's, psoas, Murphy's, Obturator sign. Bladder palpable?
• Female: inspection for discharge, lesions, genital warts, pubic hair, symmetry, discoloration. Palpation: masses, enlargement or discharge from urethra, Skene's of Bartholin's glands. Vaginal canal: rugae, lesions, masses. Cervical os: color, closed, indurated, lesions? Bimanual: tender, firm, smooth? Cervix: discharge pain. Uterus: smooth, nodules, masses, lumps. Adnexal masses, tenderness.
• Male: Circumcised/uncircumcised. Glands: ulcers, scars, nodules inflamm. Skin: excoriation, nits or lice. Milk urethral meatus. Palpation: tender, induration, corpus spongiosum, corpus cavernosum deformity, rupture. Scrotum: rashes, swelling, lumps, engorged veins. Testicles: smooth, firm, pain, spermatic cords, inguinal hernias.
.RECTAL: lesions, warts, hemorrhoids, fissures, sphincter tone, palpation for lesions or internal hemorrhoids, stool, Gualac.
.MUSCULOSKELETAL: Motor strength 5/5 all joints?
TMJ: Inspection, palpation, ROM, crepitus, pain or clicks, inflammation.
.C SPINE: palpation, flexion, extension, lateral movement and rotation.
.T/L-SPINE: tenderness, abnormal curvature, ROM, pain, crepitus
.ELBOWS: ROM, pain, crepitus, palpate olecranon and medial and lateral epicondyles.
.HANDS/WRISTS: MP, DIP, PIP aligned, pain, swelling, deformities, ROM.
.HIPS: pain, ROM, Arock hips@, sacral stability?
.KNEES: pain, deformities, swelling, warmth, ROM, Bulge sign, McMurphy's, Lachman's sign, patellar position and condition.
.FEET/ANKLES: pain, metatarsophalangeal joint, swelling, deformities, ROM of ankles & toes.
.NEUROLOGICAL: neuro deficit, atrophy, CN deficit I-XII {see below}. Bicep, tricep, brachioradialis, patellar deep tendon reflexes, Achilles reflexes +2? Muscle strength tests 5/5? Pain/temperature, vibratory/positional senses for upper and lower extremities, graphesthesia, stereognosis, heel to toe walking, gait, stationary, Rhomberg, Babinski.

CN I- Smell
CN II- Vision
CN III, IV, VI- EOM, pupillary responses, direct and consensual
CN V- corneal reflex, facial sensation, jaw opening, and bite strength
CN VII- eyebrows raise, eyelids close, smile, frown, pucker, and taste
CN VIII- auditory acuity bilaterally, Rinne/Weber test
CN IX, X- palatine elevation, swallow, phonation, gag reflex
CN XI- lateral head rotation, neck flex, shoulder shrugs
CN XIII- tongue protrusion, strength of lateral deviation
Diagnostic tests and procedures are classified as:
• Invasive - procedures that involve introduction of needles, catheters, or other instruments into the body.
• Noninvasive - procedures that entail little or no risk or discomfort to the patient. Examples are urinalysis or x-rays.
Categories of diagnostic tests include:
• laboratory tests - blood and urine concentrations of substances; organ function tests
• electrophysiological - electrocardiogram (ECG); electroencephalogram (EEG); electromyelogram (EMG); evoked potential (EP)
• radioisotope (radionuclide) - radioactively labeled substances are used to measure function
• Endoscopy - instruments used to view the interior of the body; consist of some form of tube, a light source, and lenses; proctoscope, sigmoid scope, laparoscope, etc.
• Ultrasound - high frequency sound waves that are mapped as they echo back from internal organs and tissues resulting in a picture of interior structure; commonly used to examine heart valves, gallstones, and the uterus during pregnancy among other uses.
• x-ray (radiographic) - standard x-rays (e.g., chest to look for signs of pneumonia or TB, or bones for fractures, subluxations, alignment, etc.); mammogram; angiogram; arteriogram
• computerized tomography (CT) - produces cross section x-ray pictures
• Magnetic resonance imaging (MRI)/functional MRI similar in appearance to CT however patient is not exposed to radiation but is exposed to strong magnetic fields and radiowaves. Patients with metal implanted in their body cannot undergo MRI. MRI produces more detailed image of tissues such as nervous tissues.
• Positron emission tomography (PET) - used to measure function by injecting patient with a substance such as glucose labeled with a positron emitting isotope and measuring the distribution and metabolism of that substance.
• cytological/histological - Papanicolaou (Pap) smear; biopsy
While it is impossible to discuss every possible treatment available for patients, the types of treatment may be categorized as per your diagnosis …………………

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Comment by DR. Sushil Bahl on October 14, 2010 at 2:35am
We need to confirm the diagnosis for each and every patient, being treated by us, beside the therapeutic diagnosis.
The use of diagnosis in Homoeopathy, is mostly, for the purpose of prognosis, and elimination of common symptoms.
Diagnosis, though essential ,yet is of no or little help in the selection of the homoeopathic remedy.
Comment by Dr Muhammed Rafeeque on October 12, 2010 at 12:32am
Dear doctor,
Thanks for posting a very useful article.

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