The four examinations Flashcards
What are the four diagnostic methods?
Inspection
Smelling & listening
Inquiry
Palpation
What is inquiry?
Inquiry (asking) is verbal interaction with the
patient to obtain information used to help develop an accurate diagnosis.
What are the 10 questions?
- Hot and cold (chills and fever)
- Sweating
- Head and body (limbs)
- Stools and urine
- Food and drink
- Chest
- Hearing
- Thirst
- Gynaecology (women)
- Children’s questions (paediatrics).
What are the two main areas of questioning?
General information e.g contact information, previous medical history, personal life history, family history.
Specific information: chief complaint, present medical history.
What are the five humors?
Heart = sweat Lung = nasal mucus Liver = tears Spleen = salvia Kidney = spittle
What would you ask the patient about chills and fever?
Are the chills and fever simultaneous? Chills only or fever only? Alternating chills and fever? Onset and duration? Do the chills or fever get worse in the morning, noon or evening? Duration: is it chronic or acute?
What would you ask the patient about sweating?
Whether there is sweating or not. When is does sweating occur (time of day) Location of the sweat on the body. Quantity of sweat Character of sweat
What would you ask the patient about the head and the body?
There could be dizziness, headaches.
Distention in the belly, palpations.
Mental health.
What would you ask the patient about stools and urine?
Consistency Colour Frequency Texture Pain Blood in the stool Smell Sensation after defecation
What would you ask the patient about food and drink?
Cravings Hot or cold Cooked or raw Frequency of eating Sensation after eating and drinking
What would you ask the patient about the chest?
Palpations, pain in the chest, shortness of breath, distention, discomfort.
What would you ask the patient about thirst?
Is there thirst or no thirst?
Desire to drink warm or cold drinks?
Appetite
What would you ask the patient about gynaecology?
What menstruation is like? Is there pain? Colour of blood Colour of vaginal discharge How long does their period last for?
What would you ask the patient about children?
Was the pregnancy full term?
What the labor premature?
Breastfeeding etc.
What would you ask a patent about pain?
Ask them about the location of the pain
The sensation of the pain
Duration of the pain
Time of the day.
What would you ask a patient about pain?
Ask them about the location of the pain
The sensation of the pain
Duration of the pain
Time of the day.
What is the scope of inspection?
Inspection of the whole body Inspection of local areas Inspection of the infant’s index finger Inspection of excreta and secretions Inspection of Tongue
How do you observe someone’s body form?
Constitution: body type, musculature, joints, posture and movement.
Demeanour
Shen (spirit)
What are the five constitutional types in relation to the elements?
Wood: Slender, tall body shape, broad shoulders, straight back.
Fire: Pointed head or chin, small hands, with curly or a small amount of hair and small hands.
Earth: Large head, rounded body and large belly, strong thighs, a wide jaw.
Metal: broad square shoulders, strongly built body and a triangular face.
Water: round face and body, with a longer than normal torso
How do you observe Shen?
State of vibrancy reflected outwardly in the appearance of a person: within the tongue and the pulse.
Lacking Shen is lacking vibrancy which can be seen in the facial expression, skin, eye movement and voice.
What can you observe in someone who has Shen?
If a person has Shen the complexion is bright, the facial colour is clear, the eyes sparkly, the mind is clear resulting in good communication. The breathing and voice are even.
Why is the eye regarded the window of Shen?
There is an emphasis on observation of the eye movement, the expression of the eyes.
The eye is regarded as the window of the Shen.
The eye is the messenger of the Heart.
All the essence and Qi of the five Zang and six Fu rise and pour into the eyes.
How does observation of the face tell you about your patient?
Facial expressions: inform the practitioner about the psychological status of the patient, whether it be sad, happy, anxious or worried, and are a point of consideration prior to making a diagnosis.
Facial Features: the features themselves, including the shape, markings, complexion, colours and sheen can provide evidence of excess or deficient conditions.
How do you observe the eyes?
The Liver opens to the eyes (sense organ associated with Wood element).
The function of the Liver is to store Blood, the nutritive resource for the eyes.
The Liver also controls the tendons to maintain normal vision and movement.
Changes in vision tend to relate to the Liver.
How do you observe the nose?
The nose is located in the centre of the face which is associated with Earth and governed by the Spleen.
The bridge of the nose reflects the Liver.
The Lung opens into the nose and is responsible for smelling and is the passageway of inhalation and exhalation.
The Yang Ming channels and Tai Yang channels all directly connect to the nose.
If the nose is moist it indicates that any disharmony in the body is not serious.
How should you observe the mouth and the lips?
The mouth & lips reflect the state of the Spleen & Stomach.
The Spleen and Liver govern the muscles and tendons which enable form and movement.
Breathing should occur through the nose, if there is mouth breathing, which means that the mouth is always open, it indicates Lung Qi deficiency.
The lips should be red, lustrous, moist and flexible reflecting an abundance of Spleen Qi & Blood.
How do you observe the teeth and the gums?
Teeth are the surplus of bone and therefore directly related to the Kidney.
Teeth should all be present and be bright
and moist.
The Yang Ming channels pass through the gums therefore the gums can reflect disorders of the Stomach and Colon.
Gums should be moist, pink and free of bleeding, ulcers or swelling.
How do you observe the throat?
The throat is the gateway to the Lung and Stomach
The throat is the structure that produces the voice
Several channels either directly or indirectly connect to the throat:
Liver, Gallbladder
Kidney
Heart, Small Intestine, Pericardium
Spleen, Stomach
Lung, Colon
Du Mai
Chong Mai
Changes in the throat can therefore reflect Zang-Fu disorders
The throat should be light red/pink, moist and permit smooth swallowing.
How do you diagnose in children under the age of three?
Wind-gate is at the metacarpophalageal (MCP) joint.
Qi-gate is at the proximal interphalangeal (PIP) joint.
Life- gate is at the distal interphalangeal (DIP) joint.
From the palm to the tip of the finger, the first joint is Fengguan (Wind-gate), the second is Qiyuan (Qi-gate) and the last is Mingguan (Life-gate).
When inspecting the tongue what are you looking for?
The tongue spirit. The tongue body. Body colour, surface markings Body shape, size, texture The tongue coating (moss). The tongue bearing (motility). Flexibility Abnormal movements Abnormal length The tongue moisture. The hypoglossal veins.
What should the quality of the tongue be like in a normal state?
The tongue spirit reflects the condition of the Zang-Fu, Qi, Blood & Body fluids.
When they are all abundant the tongue will appear pink, bright & moist.
It will be flexible and able to detect the five tastes.
When this is the case, the tongue is said to have spirit.
What does the tongue body indicate?
Tongue body colour indicates the state of Blood, Ying Qi & the Zang-Fu.
It depends on the volume of Blood filling the tongue.
It reflects conditions of Yin/Yang, Hot/Cold.
What does tongue body shape refer to?
Tongue body shape refers to the external form of the tongue.
It indicates the condition of Blood, Ying Qi & the Zang-Fu.
It reflects conditions of Fullness/Emptiness.
A change in the shape indicates a more severe condition than if the shape were unchanged.
What does the coating of the tongue tell us?
The Tongue coating indicates the state of the Fu.
It reflects conditions of Hot/Cold, Fullness/Emptiness.
What does tongue moisture tell us?
The Tongue moisture indicates the state of the Jin-Ye.
A healthy tongue is moist, but not overly wet.
A dry tongue indicates insufficient body fluids.
An excessive amount of fluid indicates Yang deficiency.
What do hypoglossal veins on the tongue tell us?
Under normal conditions two bluish purple veins can be seen under the tongue, lateral to the frenulum.
Their length is no more than 1/3rd the distance from the base of the tongue to the tip.
They are no more than 2.7mm in diameter.
They have no branches, or bulges.
Variations from the above, such as increased thickness or length, or a darker colour indicate Qi & Blood stagnation.
How is the tongue related to the organs?
Heart: opens into the tongue and enables speech.
Spleen: the tongue as a muscle is an external sign of the Spleen, it affects tongue movement.
The Spleen & Stomach: related the sense of taste, which in turn can affect the appetite.
Liver: controls tendons and affects tongue flexibility & movement.
Lung: affects body fluids for tongue nourishment & moisture.
Kidney: stores Jing, affects shape, size & moisture of tongue.
What organs form tongue coating?
The tongue coating is formed by the Stomach and Spleen.
It is created by the upward movement of Spleen and Stomach Yang evaporating and transforming damp turbidity.
What types of things do we listen for in our patient?
- The patient’s voice
- Use of language
- Breathing
- Coughing
- Bowel sounds
- Sneezing
- Vomiting
- Belching
- Hiccoughs
- Sighing
What do we specifically listen for?
Volume - loud or soft
Strength - strong or weak
Clarity - clear or turbid
Rate - rapid or slow
This can help us determine if there is heat or cold & if there is excess or deficiency.
What does sound indicate in terms of excess/heat and cold/deficiency?
Loud, strong = Heat, excess
Soft, weak = Cold, deficiency
What is the relationship between the 5 elements and the voice?
A shouting voice = WOOD, Liver A laughing voice = FIRE, Heart A singing voice = EARTH, Spleen A whimpering voice = METAL, Lung A groaning voice = WATER, Kidney
What is the pathology of voice?
Reluctance to speak - Lung Qi deficiency (too tired to speak)
Excessive Talking - Heart Fire
Sudden loss of voice – Invasion of Pathogenic energy, Wind-Heat usually
Gradual loss of voice - Lung Qi or Lung Yin deficiency
What could abnormal respiration reflect?
Indicates manifestation of pathological changes in the Lung, possibly also the Kidney
Excess - pathogens obstructing Lung Qi
Deficiency - Lung or Kidney Qi weakness
What is vomiting caused by?
Rebellious Stomach Qi forces the Stomach contents out through the mouth
Due to:
Stagnation of food/fluid
Exogenous pathogenic attack
Stomach Qi/Yang or Yin deficiency
What is benching and hiccoughs caused by?
Rebellious Stomach Qi
Due to:
Excess:
Pathogens accumulating in the Stomach interfering with the descent of Stomach Qi
Deficiency:
Stomach Qi/Yang or Yin xu cause the Stomach to lose its power to descend
What does excessive sighing indicate?
Involuntary process which relieves the sensation of distress in the chest
Caused by either:
Emotional stress: Liver Qi stagnation
Chronic illness: Qi/Yang deficiency
What types of odours are you looking for?
Odours of the body Odours of the mouth, nose, ears & eyes Odours of excretions & secretions Odours in a patient’s room
What is palpation?
The practitioner uses his/her hands to touch, feel, press areas of the body to feel for local abnormal changes to help differentiate the pattern of disharmony.
What does the skin reflect when we are palpating?
Temperature: reflects the Cold & Heat in the body
Moisture & Dryness: reflects the sweating function & the state of body fluids
Texture: reflects the condition of Qi & Blood
Swelling, rashes, sores & boils: reflects Qi stagnation, Qi & Blood deficiency, Dampness, Cold or Heat
What do the hands and feet indicate?
The temperature of the hands & feet reflect the state of Yang & Qi
Assessing the temperature can help determine whether the pattern is Internal or External, Full or Empty, Hot or Cold
Generally cold hands & feet are caused by Yang xu or Yin predominance
Hot hands & feet are caused by Yin xu or Yang predominance
What does the hypochondrium reflect in terms of organs?
Includes the lateral side of the rib cage and area immediately below it
Reflects state of the Liver and Gall-Bladder
What does the epigastrium reflect?
Area contained between the xyphoid process, costal margins and the umbilicus
Reveals the condition of the Stomach and Spleen
What does the umbilical region reflect?
It is the area right around the umbilicus
It reflects the state of the Small Intestine, Kidneys, the Penetrating (Chong) and Directing Vessels (Ren)
Umbilical area has a palpable pulse as well
What does the lateral lower abdomen reflect?
Also called Shao Fu
Reflects the state of the Intestines and the Penetrating Vessel (Chong)
Hard – Dampness in intestines or Blood stasis in Penetrating Vessel
Pain – blood stasis in Penetrating Vessel
Feeling of mass – Blood stasis in the Intestines or the Penetrating Vessel
What does the central lower abdomen reflect?
Also called Xiao Fu
Reflects the state of the Small Intestine, Kidneys, Bladder, Uterus and Liver
What are the reasons for acupuncture point palpation and what are the indications?
The main reason for point palpation is checking for tenderness.
Very tender on superficial pressure – Full condition on that channel or local stagnation.
Pressure relieves pain – Empty condition on that channel or region.
Pressure relieves but then causes discomfort – mixed Deficiency and Excess condition.
All acupuncture points (and Ah Shi points) can be used diagnostically.
What are the front Mu points?
Mu – “raise, collect, enlist, recruit”
Points where the Qi of the relevant organs collects
What are the back shu points?
Points are all located on the Bladder channel
Reflect specifically the condition of the relevant internal organ instead of its channel
In relation to the pulse what is qi and blood associated with?
Qi is associated with Yang - movement of the blood in the vessel
The power of the pulse.
Blood is associated with Yin - the substance that fills the vessel
The substance of the pulse.
What happens to the pulse if qi and blood are deficient?
Qi
It fails to move the Blood
The pulse will be forceless
Blood
It fails to fill the vessel
The pulse will be thin
How is the pulse a reflection of the Zang-Fu?
The Heart continuously pumps Blood and Qi into all parts of the body through the vessels.
The Lung governs Qi - Blood circulation depends on distribution of Qi by the Lung.
The Spleen & Stomach generate Qi and Blood from food & drink.
The Spleen also holds the Blood in the vessels.
The Liver stores Blood and regulates the quantity of Blood in circulation
It also ensures the smooth flow of Qi
The Kidney stores Jing which is transformed into Blood
Jing also gives rise to Yuan Qi which transforms Gu Qi into Blood.
What are the three methods?
Systemic Pulse Taking requires taking the pulse at 3 separate locations on the body Head (upper) Hand (middle) Foot (lower)
Ren Ying pulse (carotid artery at St 9): relates to Stomach Qi
Chong Yang pulse (dorsal artery of foot at St 42): relates to Stomach Qi & Kidney Qi
Cun Kou pulse (radial artery): relates to the 12 channels
Cun Kou – single radial artery pulse taking
The Classic of Difficulties established the practice of feeling the pulse at the radial artery
This method is the most prevalent method used today because of the accessibility of the radial artery and its clinical accuracy
What is the definition of Cun Kou?
The distance from the wrist crease to the styloid process of the radius is 1 cun.
Kou means gate, gap or pass and suggests the area on the pulse that we palpate.
What are the locations and divisions of the pulse?
There are three sections of the pulse at the radial artery.
Distal position - Cun , the most distal of the three positions, also called the front position or first position
Middle position - Guan , located medial to the styloid process of the radius at the wrist, also called the second position
Proximal position - Chi , adjacent and proximal to the middle position, also called the rear position or third position
What are the positions of the ZangFu in relation to the 3 pulse positions?
Left hand:
Cun: Heart and small intestine
Guan: Liver and GallBladder
Chi: Kidney Yin and Bladder
Right hand:
Cun: Lungs and LI
Guan: Spleen and Stomach
Chi: Kidney Yang and triple energiser.
What are three depths in relation to the pulse?
Superficial depth
When the skin is lightly touched the pulse is felt at the skin level (superficial)
Middle depth
When a moderate amount of pressure is applied the pulse is felt at the muscle level (middle)
Deep depth
When a heavy pressure is applied the pulse is felt at the bone level (deep)
How does the position effect the pulse and what is the correct body position for pulse taking?
The posture & position of the patient can affect
Qi & Blood circulation.
The correct posture & position of the patient should be sitting up straight or lying on his/her back with the arms extended at the same elevation as the Heart.
Palm facing upward, wrist extended, fingers relaxed, with a soft cushion placed beneath the wrist.
What are you looking for in pulse diagnosis?
What you should pay attention to
(in this specific order)
Feel the Pulse as a whole
Feel whether the pulse has spirit, Stomach Qi and root
Feel the three levels and the three positions
Feel the strength of the pulse
Feel the quality of the pulse
What are the four different ways that the pulse is felt?
Pulse is felt by moving the fingers in 4 different ways:
Lifting (upwards)
Pressing (downwards)
Pushing (side to side)
Rolling (proximal – distal)
How long should you spend taking the pulse?
The time spent taking the pulse should be not less than 50 breaths (2-3 minutes)
What are the characteristics of a normal pulse?
Characteristics of the normal pulse
The normal pulse is full of Stomach Qi (Stomach)
calm, gentle, regular with moderate strength & relatively slow (4 beats per respiratory cycle)
The normal pulse is full of Spirit (Heart)
unified rhythm in a soft vessel; regulated – should not easily change type
The normal pulse has Root (Kidney)
clearly felt at the deep level in all 3 positions. Kidney pulses are strong
Stomach Qi, Spirit and Root cannot be separated, if it has Stomach Qi it must also have Spirit & Root
What factors influence the pulse?
Age - the strength and quality of the pulse will decline as a person ages.
Gender – Men’s pulses are generally stronger on the left and women’s are generally stronger on the right
The male pulse is naturally stronger overall than females
The female pulse may be weaker, thinner and slightly more rapid than the male pulse.
Other factors
Mental/emotional state
Physical labour or exercise - those who perform strong physical labour have a stronger pulse than those who do not.
How do seasonal changes influence the quality of the pulse?
Spring - more wiry
Summer - flooding
Autumn - floating
Winter - deeper
What is a superficial pulse?
A Floating (Superficial) pulse is felt as soon as the fingers touch the skin.
What is a sinking (deep) pulse?
A Sinking (Deep) pulse is defined as a pulse that cannot be felt until the pulse is pressed two thirds of the way down to the bone.
It feels distinct only at the deep level.
It is normal for the chi positions to be slightly deep.
A Deep pulse is essentially associated with interior patterns.
What is a forceful pulse?
Forceful - full, wide and strong, felt with strength at all levels.
Strong Qi & Blood fighting off an invasion by pathogenic factors, or stagnation of Qi and Blood.
What is a forceless pulse?
Forceless - empty, wide but not strong, disappears with slight pressure.
Deficiency of Qi & Blood which fails to fill and move the Blood in the vessels.
What is a slow pulse?
A Slow pulse has 3 or fewer beats per respiration cycle.
(< 60bpm )
The Slow pulse is principally associated with Cold and Yang deficiency.
It may occur in any disease involving insufficiency of Yang or obstruction of Qi movement, such as Cold, Phlegm and Blood stasis.
What is a fast pulse?
A Rapid pulse has more than 5 beats per respiration cycle ( > 90bpm )
One having between 5 and 6 beats is termed a
slightly Rapid.
More than 6 beats is very Rapid.
The Rapid pulse is associated with Heat.
A forceless fine Rapid pulse indicates Yin deficiency with Empty-Heat.
A forceful Rapid pulse indicates full Heat and is
most commonly seen in febrile diseases.
What does rhythm of the pulse refer to?
The rhythm of the pulse mainly depends on Heart Qi/Yang.
The pulse beats with a regular rhythm when Qi & Blood move smoothly.
When Qi is deficient or obstructed the pulse will beat irregularly
What happens when heart yang fails to keep blood moving in the vessels?
Knotted: slow with irregularly missed beats
Hurried: rapid with irregularly missed beats
Intermittent: regularly skipped beats
What does it indicate when there is a change in the pulse shape and tension?
Excess pathogenic factors obstructing the flow.
Qi , Blood or Jing deficiency which fails to fill the vessel and causes the shape to change.
What is taut and slack?
Taut: feels tight and hard due to stagnation or constriction
Slack: feels soft & loose due to Qi & Blood deficiency
What is a choppy pulse?
Rough and uneven
What is a slippery pulse?
Smooth with a viscous sensation
What is a tight pulse?
Tension with side-to-side movements
What is a wiry pulse?
Tension with not side-to-side movements
What is a wide and thin pulse?
Wide - broad with distinct edges
Excess Heat expands the vessel
Thin - fine with distinct edges
Insufficiency of Blood & Yin fails to fill the vessel
What is a long pulse and what is a short pulse?
Long - increased Length,felt beyond the 3 positions
Excess (heat usually), filling the vessel
Short - decreased Length, not felt in all 3 positions
Deficiency or obstruction preventing the Qi & Blood from filling the pulse
