Friday, March 02, 2012
By David C. Radford, DC, David R. Seaman, DC, James F. Winterstein, DC, and Robert C. Jones, DC. Reprinted with permission from the American Chiropractic Association, www.acatoday.org.
In part one of this
three-part series we discussed the history of the chiropractic
profession and primary care, both past and present (see ACA News,
January 2012, Page 29). In part two, we discuss the implementation
of conservative primary and clinical methods to start to address
wellness and preventive medicine without prescriptive rights. It
becomes clear that we currently treat patients with primary care
issues that are not being fully addressed, and that we are
naturally positioned to fill in the treatment gap.
We go to chiropractic school, and we learn about all the common and not-so common problems that we face as human beings. We learn about all sorts of injuries and the mechanisms of healing processes as well as their limits. We learn about infectious diseases and the pathology of chronic and degenerative illnesses, as well as the diseases of poverty and excess. However, there may be an essential fl aw in the education process that we need to overcome if we are to help our patients live longer and healthier lives. Our shortcoming is not in obtaining the patient's full life story; rather it involves the proper application of patient management options available to us.
Today all of the students coming out of chiropractic college should know the following initials by heart: CC, HPI, PMH, FH, SH and ROS, from which a vast amount of information is derived. Much of this information helps to identify: 1) factors that perpetuate painful musculoskeletal conditions, such as vitamin D defi ciency, and 2) relevant comorbidities, such as hypertension or the metabolic syndrome that may need to be addressed to thoroughly treat the patient.
CC: Chief Complaint is usually just one sentence in the patient's own words. It can be elicited with a very simple question: "What brings you in today?" The answer is commonly something like "I have low-back pain."
HPI: History of Present Illness is simply the patient's answers to a series of routine questions from the doctor. "When did the back pain begin? What were you doing at the time? What makes your back pain better? What makes it worse? Does the pain spread anywhere? Have you had similar symptoms in the past? What have you done for it? Have you seen anyone else about your back pain? If so, what was done and what was said to you? Were any tests ordered, and what did the tests show? Have you tried any medication? Did the medication help you? Did you have any reaction? Do you have any bowel or bladder symptoms?"
PMH: Past Medical History consists of a series of questions to look for any illness that may still need attention. We should ask about any hospitalizations, past surgical procedures and the outcomes. What are current medications, supplements and environmental factors that may infl uence health or outcome, medications or food allergies, as well as quality of diet? For women, include gynecological history, the number of pregnancies, childbirths, miscarriages, abortions and menstrual abnormalities. If the patient is postmenopausal, what was the approximate date of her last menstrual period (LMP)? This LMP date is useful to start a discussion about bone health, the risks of osteopenia and the treatment necessary to help prevent osteoporosis.
Ask patients about any accidents or injuries and how they were treated. Are there any residual symptoms? Learn and record the name of their primary care physicians (PCP) and any specialists. This is a good time to ask your patient if you should communicate your fi ndings and treatment plan to his or her PCP. This type of doctorto- doctor communication leads to integration; it helps eliminate any redundancy in medical services, thus helping lower this patient's health care costs.
Under PMH, make a list of potential chronic problems or comorbidities for patients that can affect care or delay healing. You can ask your patients if they have a history of heart disease, elevated lipids, mitral valve disease, deep vein thrombosis or high blood pressure. In male patients with risk factors and in women over 65, ask if they are taking baby aspirin. Ask about a history of tuberculosis, rheumatic fever, diabetes mellitus, stomach ulcer, gastrointestinal complaints, urinary complaints or infl ammatory arthropathy. You may want to ask patients if they sleep well and if they have any history of a seizure disorder or psychiatric problems. Depression and anxiety are very common. Given the links among periodontal disease, heart disease and rheumatoid arthritis, ask them about their routine dental health.
FH: Family History is an opportunity to peek into the patient's genome. Does the family history provide any areas where he or she has increased genetic risk factors that need to be considered either short or long term? This might include something like a family history of prostate, breast or colorectal cancer, as these diseases are believed to be largely preventable. Modulation of chronic disease is a hot topic these days. A great deal of research is being done in the prevention of chronic illness, and ongoing education is a key to better understanding the prevention and management of chronic illness.
SH: Social History topics in adults should include marital status, occupation and the highest level of education and military experience. Social history questions are sometimes very personal, so common sense and discretion are important. While it may be inappropriate to ask a child about sexual activity, it is perfectly appropriate for any patient of childbearing age, even if single. Does the patient have a sex partner(s), and what is his or her lifestyle like, and would it create risk of a viral infection? Does he or she use barrier protection? Asking a senior about sexual activity can be quite telling in terms of general health and happiness.
Ask about tobacco, alcohol and drug use. Is there an indication or a history of drug or alcohol abuse? Does the patient smoke or not smoke? Did the patient quit, and, if so, how many years ago? How many years did the patient smoke? By doing this you are not just showing your interest as a physician; you are preparing a conservative primary care plan for the patient's health and well-being.
ROS: Review of Systems usually starts with a lengthy questionnaire. It is typically completed by the patient before seeing the doctor. It should be thorough and cover all the systems of the body. Computerized patient registration can be completed from home and then sent encrypted to the office prior to the first visit.
Diagnosis and Treatment
By following this traditional format of taking a comprehensive patient history, you have already helped plan the focus of the physical examination. The patient interview has allowed you to assess the patient's memory, cognition and mental health to some extent. The history and physical examination can be used to plan appropriate imaging or laboratory testing to arrive at a working diagnosis and treatment. Objective measurements such as patient vital signs and body mass index, as well as a discussion of energy level, may point you in the direction of simple laboratory tests like urinalysis, a CBC and differential, erythrocyte sedimentation rate and fasting metabolic panel; if there is a risk of diabetes or heart disease, a hemoglobin A1c (HbA1c) and a lipid profi le should be discussed.
Having the patient's vital signs and the lipid panel results allows us to calculate the Framingham Risk Score to plan care. Measuring the high-sensitivity CRP (hs-CRP) allows us to assess the level of endothelial infl ammation and the risk of a cardiovascular event. In both men and women, ordering a 25 OH vitamin D level better enables you to talk about bone health and a number of chronic conditions, such as chronic pain, depression, cardiovascular disease, cancer, and even the risk of upper respiratory infectious disease.
A patient with the primary complaint of back pain may also be suffering from metabolic syndrome, hypertension and atherogenesis. Traditional thinking maintains that these are separate conditions- mechanical pain that needs manipulation and metabolic conditions that require medication. However, we now know that all of these conditions, including back pain, can be caused by glycemic dysregulation, hyperlipidemia and vitamin D defi ciency (1-6), which are generally non-responsive to medications in the long term. Lifestyle changes are required to prevent and help reverse the symptoms generated by an aberrant lifestyle; those changes include exercise, dietary modifi cations and nutritional supplementation.
While there are many possible scenarios, this brief clinical example highlights that metabolic abnormalities should not be viewed as distinct from mechanical pain. Such primary care metabolic abnormalities are extremely common and are responsive to natural therapies. Doctors of chiropractic are the physicians most poised to embrace this lifestyle treatment approach to address primary care problems. In other words, for many patients, resolution of chronic back pain may require a primary care approach, so why not embrace this tremendous opportunity?
Dr. Winterstein is the president of National University of Health Sciences, Dr. Jones is the president of New Mexico Chiropractic Association and ACA's delegate to New Mexico, Dr. Radford is the director of the Chiropractic Clinic of Solon, and Dr. Seaman is a professor of clinical sciences at National University of Health Sciences' Florida campus. Drs. James Lehman and Michael Taylor also contributed to this article.