12. ADVANCED CASE TAKING Flashcards
This module covers: • Naturopathic case taking. • Naturopathic case analysis • Naturopathic evaluation tools: Nail, tongue, facial, urine and stool. • Case summaries.
When taking a case:
What are the five naturopathic principles that should be applied to every client?
- The healing power of nature.
Self-healing can occur given the right means. - Treat the cause, not the symptoms.
- Treat the whole person.
Recognise individuality of the ‘whole’ person. - Prevention is preferable to cure.
- A naturopath is an educator / teacher.
Empowering clients to take responsibility for their health.
Recap:
What are ‘Hering’s Laws of Cure’?
- From the inside out; a boil clears internal toxins away from more vital organs to the skin.
- From more important organs to less; from the lungs (asthma) to the skin (eczema).
- The mind gets better before the body;
anxiety starts improving before IBS does. - Symptoms disappear in the reverse order of when they arrived.
- From above to below; progression of disease — fingers, wrists, elbows –> elbows, wrists, fingers.
Applying Hering’s law of cure:
What symptoms may be experienced before osteoarthritis of the hip results?
Osteoarthritis of the hands or spine
Correct me if I’m wrong!
When thinking of disease as a process:
What are:
1. Antecedents
2. Triggers
3. Mediators
- Predisposing factors to illness
- What Provoked / started the problem
- Factors that Perpetuate / keep the illness going
What is the role of the naturopathic practitioner when a client asks for help with symptoms?
Disease is an end result: clients describes symptoms, our role is to find the cause and encourage the body to heal itself without suppressing the symptoms.
Why would treating the symptoms of a disease be unlikely to resolve it?
What is the naturopathic approach?
Underlying imbalances lead to symptoms. Treating the individual symptoms doesn’t address to the cause. “It is not what is wrong, but why”.
Naturopathic nutrition addresses the foundations of health through dietary and lifestyle adjustments.
In Case Analysis, which five steps do you follow whilst applying naturopathic principles?
- Gather all the client’s information: Case history form, health concerns (HC), presenting symptoms, medical history, medication, family history, height, weight / hip-to-waist ratio, diet diary.
- Highlight and note down all Antecedents, Triggers, Mediators.
- Plot the information on a timeline.
- Identify which systems are under stress.
- Decide which are the core clinical imbalances for the naturopathic summary.
There are many things that can predispose an individual to a disease. List four ANTECEDENT categories that can commonly be considered.
Genetics and constitution:
-Diseases in family (i.e. parents, brothers, sisters, grandparents, aunties, uncles).
-Constitution (e.g. hot, cold, moist, dry), and the energetics of the individual’s life stage.
Age and sex:
-For example, older women are more susceptible to developing osteoporosis due to the effects of declining oestrogen on bone density and normal ageing changes. However, these are compounded by other factors (i.e. lifestyle, diet).
Lifestyle / environment:
-Nutritional deficiency e.g. folate and neural tube defects.
-Dietary toxins (e.g. pesticides, additives); alcohol or cigarette use.
-Drugs (e.g. antibiotics and the subsequent impact on the microflora and immune development) operations e.g. tonsillectomy.
-Other toxins: Pollution, heavy metals.
Historical trauma:
-Physical / emotional trauma e.g. accident, surgery, shocking events, abuse, labour.
If a client comes to see you with IBD & has symptoms of abdominal pain, diarrhoea, bloating, urgency, rectal bleeding (red flag). What might the predisposing factors have been?
*Suppression (e.g. anti-diarrhoeals for gut infection; steroids for IBD; antibiotics—which disrupt the microflora, compromising the intestinal barrier and immune system, and promoting dysbiosis).
*A poor diet high in refined carbs and low in fibre, low in essential fats and vitamins that support mucous membrane integrity and immune balance.
*Chronic stress (compromises gut integrity, making it more prone to inflammation and permeability.
Describe the ‘symptom tree’
The root cause: Imbalances begin at the ‘root of the tree’ and include ‘traumas’ and lifestyle factors throughout lifecycle stages.
*Gestation Birth Childhood Teenage years Adulthood.
*Underlying imbalances lead to symptoms.
*Symptoms are the end result (i.e. the ‘leaves’ of the tree). Treating the individual leaves doesn’t get to the root.
*It is not what is wrong, but why.
*Naturopathic nutrition addresses the foundations of health through dietary and lifestyle adjustments.
Genetics mean that each person is genetically unique.
1) describe 2 ways that epigenetics can impact a person.
2) describe 2 ways in which congenital factors can impact a person.
1) Genes can switch on or off, due to the environment.
*This means two things —genetics can influence the person, but the expression of genes can be altered throughout (eating junk / organic food; smoking / detoxing) —switching genes on or off to create or prevent the disease.
2) Congenital factors can be affected by:
*Gestational environment during pregnancy. Low / high birth weight and infections.
*Environment on the epigenetics of the baby.
List four TRIGGER categories that can commonly be considered.
Common triggers include:
* Physical or emotional trauma - ‘never been well since…’
* Microbes e.g. H. pylori, food-poisoning microbes
* Medications e.g. antibiotics (eczema after vaccination).
* Dietary allergens and / or chemicals.
* Stressful life events (divorce, problems at work).
* Environmental / domestic toxins.
* Temperature change e.g. asthma and osteoarthritis in winter.
When taking a case history what would you include to ensure that your case taking was as comprehensive as possible?
Medical history, illnesses, surgeries, vaccinations, current and past medications, pregnancies, major emotional events.
*Ask: If there was a critical incident when their health changed.
*Use ‘open-ended’ questions: E.g. “when did it start?”, “what happened at the time of onset?”, before gradually funneling into more closed questions for clarification.
*Lab testing for trigger factors: Parasitology, dysbiosis (stool testing), heavy metal toxicity, hair mineral analysis (e.g. from a mercury filling).
*Other forms of testing: Kinesiology (muscle testing), NAET (an allergy elimination technique, www.naet.com), Bio-resonance (machine to measure and positively influence EMFs).
What are Mediators? List some MEDIATOR categories that can commonly be considered.
Mediators are factors that contribute to pathological changes and dysfunctional responses. These factors can include physiological and emotional changes, but as naturopaths, we must still establish what is causing this.
Physiological mediators (with example causes) include:
- Chronic stress —hormones (e.g. due to work problems) can = ↑cortisol + ↓ progesterone. This can be associated with menstrual problems, for example.
- Intestinal dysbiosis—neurotransmitters:(e.g. caused by a western diet, antibiotic use etc.) = ↓melatonin, ↑oxidative stress.
- Sedentary lifestyle —neuropeptides: ↑substance P = ↑ pain.
Mediators (biochemical):
*Free radicals: Increased risk of Alzheimer’s and cardiovascular disease due to free radicals produced from smoking, alcohol, a highly-processed diet, medications, vaccines etc.
*Electromagnetic frequencies (EMFs):For example, TVs, computers, Wi-Fi, mobile phones and electrical wiring can disrupt sleep (lowering melatonin). Melatonin is crucial for its anti-oxidant, circadian rhythm-regulating and tumour-surveillance properties
Cognitive/emotional:
*Fear of, and level of pain.
*Personal beliefs about illness and lack of relevant health information.
*Poor self-esteem.
*How might someone feel after being told that their illness would last four weeks? Four months? Forever? How might this influence the client?
Social / cultural:
*Reinforcement for staying sick (e.g. supported emotionally and financially whilst sick, but not when well).
*Lack of resources due to social isolation or poverty
*Lack of cultural understanding.
How might lab testing be helpful in assessing biochemical mediators?
Lab testing may be helpful to discover:
–Inflammatory mediators: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), serum ferritin, calprotectin.
–Endocrine mediators: TSH, T4, fT4, fT3, oestrogen metabolism, progesterone, testosterone, cortisol, DHEA, HbA1C.
*Knowing these and where they fit in the disease process can be extremely helpful in reducing symptoms, and in preventing further disease processes
What are the seven core areas of clinical imbalance?
Core clinical imbalances:
*Seven core areas of clinical imbalance which need to be considered when deciding which systems are under stress.
*Each core area impacts overall health due to influencing multiple systems and structures. The seven core areas are:
1. Assimilation.
2. Structural integrity.
3. Communication.
4. Defence and repair.
5. Transport and circulation.
6. Energy: Mitochondrial health.
7. Detoxification and elimination.
Regarding clinical imbalance. What areas would you consider when thinking about ASSIMILATION?
Assimilation:
All aspects of digestion and assimilation:
*Digestive secretions: Stomach acid, pancreatic juices, bile, intrinsic factor (B12).
*Digestive motility and innervation: Vagus nerve, SNS, PSNS system, enteric nervous system.
*Digestive hormones: Ghrelin, gastrin, CCK.
*Absorption of nutrients: Villi, brush border enzymes.
*Microbiota balance: Parasites, bacteria, yeast, short-chain fatty acids, lactobacilli, bifido bacteria.
Regarding clinical imbalance. What areas would you consider when thinking about STRUCTURAL INTEGRITY?
Structural integrity:
Covers a range of structures in the body:
*Cell membrane health: e.g. EPA/ DHA balance.
*Mucous membrane and skin integrity: E.g. vitamin A, vitamin E (skin), glutamine.
*Bone and teeth: E.g. minerals
*Joint and cartilage: E.g. calcium, magnesium, phosphorus, vitamin D, vitamin C.
Regarding clinical imbalance. What areas would you consider when thinking about COMMMUNICATION?
Communication:
It encompasses:
*Hormones and the endocrine system.
*Neurotransmitters and the nervous system
Regarding clinical imbalance. What areas would you consider when thinking about DEFENSE & REPAIR?
Defense and repair:
This area of health covers:
*Inflammation—acute and chronic.
*Infections —↑WBC’s, ↑ESR, ↑or↓ lymphocytes and neutrophils.
*Microbiota imbalances.
*Conditions such as allergies and autoimmune disease, indicating an imbalanced and poorly-regulated immune system.
*Lowered immune function such as reduced secretory IgA which usually protects the mucous membranes.
Regarding clinical imbalance. What areas would you consider when thinking about TRANSPORT & CIRCULATION?
Transport and circulation:
This area of health covers:
*Lymphatic structures: Tonsils, spleen, thymus, nodes.
*Vascular structures: Arteries, veins, capillaries —↑waist circumference, ↑BP, ↑ferritin
*Mobilisation of blood lipids: ↑Triglycerides, ↑LDL, ↓HDL
Regarding clinical imbalance. What underlying factors would you consider when thinking about ENERGY: MITOCHONDRIAL HEALTH?
Energy: Mitochondrial health:
* Cofactors for energy production: Zn, Mg, B6, B1, B2, B3, Fe.
* Biochemical imbalances in the energy production pathways e.g. due to aluminium, fluoride, arsenic, lead toxicity.
* Mitochondrial integrity and oxidative damage.
Regarding clinical imbalance. What areas would you consider when thinking in terms of DETOXIFICATION & ELIMINATION?
Detoxification and elimination:
*Liver(and gallbladder) function.
*Kidney function.
*Bowel function.
*Skin and lungs.
*Biochemical imbalances in the biotransformation pathways e.g. lack of methyl donors (cysteine, methionine, choline, glutathione).
Regarding clinical imbalance. What signs & symptoms might you
see when considering ASSIMILATION?
Any possible insufficiency e.g. pallor, shortness of breath. Dysbiosis, gas, bloating, food allergies / intolerance, heartburn, increase or decrease in body weight, illnesses such as cystic fibrosis or any that will impede absorption.
Regarding clinical imbalance. What signs & symptoms might you
see when considering STRUCTURAL INTEGRITY?
Any issue relating to structural pain / injury, tendons or muscles e.g. osteoarthritis. Skin problems e.g. acne, eczema, psoriasis. Gut membrane integrity and autoimmune conditions. A diet low in essential fatty acids and low exposure to sunlight (vitamin D) and low bone minerals such as Ca, Mg, Zn, B, P.
Regarding clinical imbalance. What signs & symptoms might you
see when considering COMMUNICATION?
Any signs and symptoms related to hormonal issues from reproductive, and fatigue to stress to mood and sleep.
Regarding clinical imbalance. What signs & symptoms might you
see when considering DEFENSE & REPAIR?
Recurring infections, fatigue, poor wound healing, skin issues, autoimmune conditions, intestinal permeability, low vitamin D and antioxidants in the diet. High free radicals
Regarding clinical imbalance. What signs & symptoms might you
see when considering MITOCHONDRIAL HEALTH?
Any issues affecting ATP production e.g. weakness, fatigue, CFS/ ME, Parkinson’s disease, MS, poor cognitive function, poor memory, intestinal permeability.
Regarding clinical imbalance. What signs & symptoms might you
see when considering TRANSPORT?
Circulatory issues such as CVD, Raynaud’s and peripheral neuropathy. Lymphatic issues such as oedema
Regarding clinical imbalance. What signs & symptoms might you
see when considering DETOXIFICATION & ELIMINATION?
Consider when clients are on any medications, poor diet and lifestyle, poor stool quality / quantity, smoking, alcohol, exposure to chemicals, low antioxidants in the diet, poor quality / light coloured stools, jaundice, lethargy etc.
Read the following example:
54-year old male client experiences ‘utter exhaustion’. He wakes many times at night, spends most afternoons napping three-four hours. He rarely gets ill yet feels ‘fluey’ most mornings. He gets daily headaches late afternoon, which improve after a snack.
Which 3 systems are under stress?
Which core areas need support?
Main systems under stress: Endocrine, immune, nervous systems.
Core areas which need support.
*Energy: Mitochondrial health (including Krebs cycle).
*Communication: Thyroid, blood sugar, neurological concerns.
*Defence and repair: Inflammation, infection, immune dysregulation.
What 3 areas would you consider when thinking about a client’s emotional health?
Emotional considerations:
*Mental health —Cognitive function and perception. Impairment may result in dementia, sensory processing disorders etc.
*Emotional health —Emotional regulation and sense of well-being. Influenced by coping abilities, self-esteem, perception of quality of life, having a purpose in life. Imbalances may lead to suppressed or problematic emotions (consider childhood experiences).
*Spiritual health —Connection between beliefs and harmony in one’s life, based on personal values, ethics, morals and spiritual fulfilment.
*It also considers a person’s stress, resilience and relationships with friends, family and community.
When taking a case history, what are the 5 steps that are covered on the case taking form?
- Gather all of the client’s information: Case history form, health concerns (HC), presenting symptoms, medical history, medication, family history, height, weight / hip-to-waist ratio, diet diary.
2.Highlight and note down the antecedents, triggers, mediators.
3.Plot the information within a timeline: This should indicate the timings of the mediators and triggers. For example, a trigger may be a bereavement aged 38 (plot this).
4.Identify which systems are under stress.
5.Decide which are the core clinical imbalances for the naturopathic summary.
For a client whose main concern is optimal health and prevention, what would you ask about?
*Past and present health history, as well as family history.
*Risk factors for potential future illnesses, such as: Fitness, diet, sleep, alcohol, drugs, tobacco, environment at home and work, stress sources and pleasure, relationships, goals in life.
For a client with an active health problem, what would you ask about?
*What was your health like before this problem began?
*Ask about possible antecedents, triggers and mediators.
*Your questioning will then focus on where in someone’s life these triggers are occurring.
Case taking is an art, what 4 things should you aim to achieve during case taking?
Observe the client’s skin (tone, condition, markings, hair distribution), nails, tongue, posture, mannerisms.
Listen to their case / story without judgement. Pay attention to repetitive words, statements or phrases.
Clarify what the client has said, using the same words or phrases and summarise to ensure you have understood correctly.
Empower your client with knowledge —bring the case together for them and give them an understanding of why they feel like they do.
There are naturopathic evaluation tools which can help to inform a deeper understanding of the client and support the decision-making process when creating a naturopathic treatment plan. Can you name 5 of them?
The tools can also help to direct the appropriate lines of questioning to open up the consultation. These tools include:
–Tongue analysis.
–Facial analysis.
–Nail assessment.
–Anthropometric measurements.
–Urine and stool interpretations
As a nutritional therapist it isn’t in our remit to diagnose diseases or disease states such as mineral deficiencies.
If you used the rule of three and evaluated that your client needed more magnesium, give an example of how you might convey that information.
*Utilise the Rule of Three and evaluate that your client needs more magnesium, do not say: “you are magnesium deficient”, or “your magnesium intake is insufficient”.
*You say, “My evaluation indicates that you could benefit from taking more magnesium.”
*If you believe a diagnosis is needed, for example, of iron-deficiency anaemia, refer to the GP. Remember what causes iron deficiency and the effects of excess iron (i.e. feeding microbes, pro-oxidant).
What is the ‘rule of three’?
The Rule of Three requires three factors to support a hypothesis:
*Example: Your client feels anxious and can’t sleep. Look to the Rule of Three, which requires you to have three factors that support your hypothesis:
1.Low intake of magnesium-rich foods (from diet diary).
2.The client describes getting frequent muscle cramps.
3.The pupils are very dilated.
*There are three things that support your low magnesium hypothesis. What else might suggest a magnesium deficiency?
*So what do you do? 1. Correct diet. 2. Take Mg citrate before bed.
The general colour and texture of the skin can provide an insight into energetic excesses, as well as potential pathologies. What would the following signs indicate?
Strong Red?
Pale red or Malar flush?
Pallor?
Yellow?
Puffy?
Dry?
Strong Red indicates Excess heat.
Pale red or Malar flush indicates Yin deficiency, SLE, rosacea (linked to H pylori), B3deficiency.
Pallor indicates Qi deficiency, anaemia
Yellow indicates Liver / biliary disease, spleen Qi deficiency (if sallow yellow / pasty).
Puffy indicates Yang deficiency.
Dry indicates Yin deficiency, dehydration
Malar flush = red discolouration of cheeks.
In facial analysis what do the following signs indicate?
Lines across the forehead?
Lines between eyebrows?
Lines above lips?
Lines across the forehead
*Many :Poor intestinal health.
*One: Small intestine issues (decreased absorption, etc.).
Lines between eyebrows
*One: Stomach insufficiency (e.g. HCl, pepsin).
*Two: Liver imbalances (alcoholic, suppressed anger)
Lines above lips
*‘Purse strings’ on upper lip (reproductive organ weakness / blood deficiency / smoker).
