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Essentials for Diasnosis of TCM Pediatrics

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Updated: Friday, Apr 05,2013, 1:14:19 PM
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Diagnosis is a way to differentiate syndromes and diseases through the information collected from various means of diagnosis. Since the infants are unable to express themselves, physiologically and pathologically different from adults and often crying during the diagnosis,the pulse conditions will certainly be affected, making it difficult to diagnose. Thus the doctors of all dynasties emphasized much the inspection in the four diagnostic methods, i. e. inspection, olfaction and auscultation, inquiry, pulse taking and palpation. The inspection is usually done in combination with the other three. The pediatricians should master the use of these four diagnostic methods in pediatrics well, including diagnostic methods and the pathological significance of the unusual syndromes.

Inspection

Inspection in pediatrics includes observation of vitality, facial expression, physical build, orifices, macular eruption, urination, defecation and superficial venule of the index finger.

Observation of vitality

Vitality is a general term for life activities. In the infants, abundance of the spirit, vigorous vitality, vivacious expressions, ruddy complexion, bright eyes, even respiration and quick movements, usually indicate sufficiency of visceral qi, harmony between qi and blood and good health. With such manifestations of the spirit, even if there is a disease, the disease is usually superficial and easier to cure with favorable prognosis. The manifestations of dispiritedness, dull expression, silence, somnolence or dysphoria, dull eyes, uneven respiration and inflexible movement of the limbs are all indicating seriousness of the pathological conditions or unfavorable prognosis.

 Observation of the complexion
    
Normal complexion of the infants, regardless of the colour of the skin, is ruddy and lustrous, indicates harmony between qi and blood and health. The normal complexion of the neonatal babies is usually tender and ruddy. Under morbid conditions, the complexion of the infants also changes along with the nature of the disease.

Reddish complexion
     
Reeddish complexion mostly indicates heat syndromes.  With the promotion of heat, more blood flows to the face.That is why the complexion is reddish. Reddish complexion and red eyes, tumescent throat and floating-rapid pulse usually signify exogenous wind-heat syndrome. While reddish complexion accompanied by high fever, thirst and brownish urine often indicates excessive internal heat. Reddish cheeks in the afternoon accompanied by tidal fever and night sweating are the signs of internal heat due to yin asthenia, while bright reddish cheeks of the infants with serious disease accompanied by pale complexion, cold limbs and profuse cold sweating indicate the critical condition of deficient yang floating upwards.
 
Whitish complexion

Whitish complexion mostly indicates cold and asthenic syndromes due to stagnation of cold in the vessels, inactivation of qi and blood as well as asthenia of the vessels and meridians. At the early stage of exogenous diseases, the manifestations of pale complexion, cold limbs, anhidrosis and floating-tense pulse indicate the superficial cold syndrome due to the attack by exogenous cold. Sudden pale complexion accompanied by cold limbs, profuse sweating and indistinct pulse indicate the critical condition of sudden loss of yang-qi. Pale complexion, lips and nails usually indicate blood asthenia, and pale complexion often signifies the overflow of water due to asthenia of yang.
   
Yellowish complexion
   
Yellowish complexion indicates asthenia and dampness syndromes due to failure of the asthenic spleen to transform dampness and fluid or damp heat steaming the liver and gallbladder. The sallow complexion accompanied by emaciation, poor appetite and abdominal distension of ten signifies asthenia of the spleen and stomach qi: bright yellowish complexion and eyes often indicates yang jaundice due to the steaming of damp heat: yellowish and dull complexion usually indicates yin jaundice due to the stagnation of cold damp.

Bluish complexion
   
Bluish complexion indicates cold, algesia, convulsion and blood stasis syndromes due to stagnation of the vessels and meridians resulting in the unsmooth circulation of qi and blood. Alternate pale and bluish complexion and worried look usually indicate interior cold and abdominal pain: cyanosed lips and complexion accompanied by dyspnea of ten signifies stagnation of the lung qi and blood stasis due to qi stagnation. Bluish and dull complexion, especially the region around the nose and the lips, often indicates premonitory convulsion or seizure of epilepsy.

Blackish complexion
   
Blackish complexion indicates cold syndrome, serious syndrome and retention of fluid due to decline of yang-qi and accumulation of fluid resulting from cold yin. Infantile bluish and blackish complexion as well as cold hands and feet indicates excessive cold yin in the interior; grayish and blackish complexion signifies decline of kidney qi; blackish complexion, dizziness, nausea, vomiting and scanty urine are often the signs of upper distribution of the turbid dampness due to kidney asthenia; blackish and lusterless complexion accompanied by abdominal pain and vomiting is usually caused by poisoning from drugs or food.

Observation of physical build
   
Observation of physical build includes the configuration and constitution and movement of the infants. The physical characteristics, active and static postures and special position of" the body all can be used as the basis for diagnosis and differentiation of syndrome. For example, squared-shaped head with scanty hair, metopism, deformity of the thorax, clustered ribs and twisted lower limbs are usually the signs of rickets; scanty hair, thin neck, bulging abdomen and emaciation usually indicate infantile malnutrition. Preference to  sleep is often due to internal damage with improper diet; preference to sleep with curled body is often due to internal cold or abdominal pain; quiet supination with dull eyes signifies serious disease, prolonged illness or extreme weak constitution; sitring up ereetly with wheezing due to sputum indicates asthma; stiff neck, spasm of the limbs and opisthotonos show infantile convulsion; writhing due to restlessness and crying with hands holding the abdomen indicates abdominal pain.

Observation of the tongue
     
Observation of the tongue is a unique diagnostic method in TCM which can judge the conditions of vital qi, and distinguish the depth of the location of the disease, differentiate the nature of the pathogenic factors and the  deterioration or improvement of the disease. That is why  the tongue diagnosis is very much emphasized in clinic.  The normal infantile tongue is characterized by softness, flexibility, pale reddish tongue proper, thin and whitish  fur as well as moderate humidity. The tongue of the new born babies is tender, reddish and furless.

Observation of the tongue proper
     
Pale tongue proper indicates asthenia of both qi and blood; reddish tip and margin of the tongue indicates exogenous wind and heat; prickly reddish tongue indicates abundance of interior heat; red or crimson tongue indicates invasion of heat into ying-blood; reddish tongue  without fur indicates consumption of body fluid; purplish  tongue indicates stagnation of qi and blood; tongue as red as bayberry indicates scarlet fever caused by toxin of  heat; bulgy and tender tongue with tooth prints usually indicates asthenia of the spleen and kidney yang or retention of fluid or phlegm; swollen and purplish tongue indicates poisoning; stiffness of the tongue indicates consumption of body fluid by predominant heat; shrunk, crimson and dry tongue is usually caused by contraction of the meridians  due to malnutrition resulting from consumption of body fluid in febrile diseases; ulceration of the tongue indicates  aphtha due to hyperactivity of heart fire; wagging of the tongue usually indicates hypophrenia or omen of convulsion.

Observation of tongue fur
    
Whitish thin fur indicates exogenous wind-cold; whitish greasy fur indicates retention of cold dampness or internal accumulation of phlegm-dampness; thick and greasy fur or fur with thick hard greasiness indicates retention of food; yellowish greasy fur indicates internal accumulation of damp heat or stagnation of phlegmatic heat:blackish dry fur indicates fire transformed from stagnation of dampness and consumption of body fluid; exfoliative fur like map indicates disturbance of gastrosplenic functions and insufficiency of qi and yin mirror-like glossy tongue
indicates exhaustion of body fluid and severe consumption of stomach qi.
    
The tongue should be observed under natural light and attention should be paid to the protrusion of the tongue. If the tip of the tongue is raised, the tip and margin of the tongue will appear reddish. Repeated forceful protrusion of the tongue may make the tongue appear reddish. In the inspection of the tongue, attention should also be paid to the stained fur with certain food or drugs. Usually stained fur is bright and shallow in colour, different from the diseased fur. If the doctor feels doubtful, he or she should ask the child or his or her parents. For exam-
ple, hawthorn and olive fruit may make the tongue turn blackish yolk, tangerine and ovoflavin may make the tongue appear yellowish; bayberry, grape and vinegar
may make the tongue look blackish brown; red-colored sugar or fruit may make the tongue appear reddish; milk and soy-bean milk will make the tongue turn whitish.
 These are all false manifestations of the tongue and should not be taken as morbid.

 Observation of the throat
    
Observation of the throat means to inspect the changes of the colour and shape of the throat. In examining the infants, the throat must be examined at the end of the examination. The normal condition of the infantile throat is slightly red and moist without swelling and pain. The respiration, pronunciation and deglutition are smooth. Reddish and feverish throat is caused by exogenous wind and  heat; reddish throat and antiadoncus are often due to exogenous wind and heat or flaring up of the gastropulmo nary fire; reddish throat and ulceration of the tonsil (or  with small whitish spots or with yellowish and whitish suppurative membrane which is erasable ) are usually caused by retention of heat virulence in the throat which  decays and suppurates; the throat covered with whitish false membrane, which is not erasable and bleeds when heavily erased or reappears after being erased, means  diphtheria.

Observation of the fingerprint
       
Observation of fingerprint means to inspect the changes of the radial superficial veins over the index finger of the infants under three years of age, a supplementary diagnostic method used to replace the pulse taking. The fingerprint refers to the radial superficial vein from Hukou, the region between the thumb and index finger, to the tip of the index finger. This vein can be divided into three sections, i. e. wind, qi and life. The first section of the finger is called wind pass, the second section qi pass and the third section life pass. Clinically the doctor uses his or her thumb to push the index finger of the infants from the life pass to the wind pass to make the vein visible. Usually the normal condition of the infantile fingerprint is slightly purplish and faintly visible below the wind pass. However many factors may affect fingerprint, such as age, subcutaneous fat, physical shape, colour of the skin, individual difference in vessels, blood circulation, oxygen in the blood temperature. Therefore, the observation of fingerprint should be done according to the normal condition of the fingerprint of the infants and in combination with the other clinic manifestations so as to make an accurate diagnosis. 2,1.6.1  Differentiation of exterior and interior syndromes according to the superficial and deep fingerprint
         
Superficial fingerprint indicates the early stage of exogenous diseases and the location of which is superficial, while the deep fingerprint usually indicates interior syndroroms.

Differentiation of heat and cold according to the reddish and purplish fingerprint
   
Reddish fingerprint indicates cold while purplish fingerprint signifies heat; bluish fingerprint means fright while blackish fingerprint indicates stagnation. For example, brightly reddish and superficial fingerprint indicates exogenous wind and cold; brownish and purplish fingerprint indicates stagnation of pathogenic heat; purplish and blackish fingerprint indicates aggravation of pathogenic heat or qi stagnation and blood stasis; bluish fingerprint indicates convulsion or pain.

 Differentiation of asthenia and sthenia according to the pale and dark fingerprint
     
Pale fingerprint, no matter what colour it is and whether it is a new disease or prolonged disease, is all the manifestation of asthenic syndrome, usually seen in the infants with weak constitution, consumption of qi and blood as well as malnutrition. Dark fingerprint with slow  rebounding after being pushed indicates sthenic syndrome, usually seen in the infants with phlegmatic dampness, heat virulence, qi stagnation and blood stasis.

Determining the conditions of the disease according to the three passes
     
Appearance of fingerprint on the wind pass indicates mild pathological conditions; appearance of fingerprint on the qi pass indicates serious pathological condition; appearance of fingerprint on the life pass indicates very serious condition; appearance of the superficial veins extending through the three passes towards the finger nail indicates critical pathological condition.

Olfaction and auscultation
       
Olfaction and auscultation refer to smelling the patient's odour and listening to the patient's voice. Listening to the voice includes infantile cry, cough, breath and speech. Smelling the odour includes the odour from the mouth, vomitus, urine and stool. Listening to cough is important in differentiating syndromes of the respiratory system. Smooth cough and expectoration indicate mild syndrome; cough with light voice and thin nasal discharge indicates the attack by exogenous wind cold; heavy cough with thick or yellowish sputum indicates the attack by exogenous wind heat; hoarse cough with yellowish and thick sputum indicates retention of phlegm and heat in the lung; dry cough with sonorous sound indicates the attack on the lung by dryness; repeated cough with echo is called proxysmal cough; hoarse cough like the bark of a dog indicates laryngitis or diphtheria.

Inquiry
   
Inquiry in pediatrics includes not only direct inquiry of the elder infants but also inquiry of their family members and the workers from nursery about state of onset. Inquiry should cover such aspects as sex, age, state of ill- ness and date of onset of the illness, treatment (including the use of drugs), personal history, vaccination and family hereditary histories.

Inquiry of pathological conditions

Inquiry of cold and fever
    
Fever can be tested by thermometer or by feeling, such as feverish palms and soles, feverish forehead and feverish sensation when the infants sucking the breast.

Aversion to cold can be known from the changes of the postures, such as snuggling up to the mother and curling themselves up when sleeping. Elder infants can be inquired directly. Fever in the infants is usually low in the morning and high in the evening. So time should be taken into account during inquiry of fever.

Inquiry of sweat
   
The skin and muscles of the infants are thin and tender, making it liable to sweating. But it is not pathological. If there is profuse sweating in the daytime or sweating right after movement, it is called spontaneous sweating due to weakness of Wei-qi defensive qi, resulting from asthenia of qi.

Sweating during sleep at night is called night sweat due to asthenia of yin or asthenia of both qi and yin. Lingering of fever after sweating indicates transmission of pathogenic factors from the superficies to the interior in febrile diseases.

 Inquiry of head and body
    
Elder infants can tell the doctor whether or not they suffer from headache and dizziness which are usually caused by high fever and anemia. Fever with pain of the limbs is often due to attack by pathogenic wind, cold, dampness and heat. In some eruptive diseases and urticaria cutaneous pruritus often appears.

Inquiry of diet
    
Inquiry of diet includes the intake of food and water. Normal conditions of food intake are regular taking of food, normal appetite and no vomiting. Anorexia and poor appetite indicate weakness of the spleen and the stomach. Preference to cold water indicates heat syndrome; preference to hot water or no thirst indicates cold syndrome; frequent drinking of water with dry mouth and lips indicates insufficiency of stomach yin and consumption of body fluid; thirst without desire to drink water indicates dampness in the middle energizer.

Inquiry of chest and abdomen
    
Stuffiness and distress of the chest and wheezing with sputum indicate stagnation of the lung collaterals by phlegm as in asthma; chest pain with fever and cough with dyspnea indicate cough due to pneumonia; epigastric and abdominal distension is often caused by retention of indigested food; abdominal dull pain around the navel is often seen in ascariasis. Besides, acute and severe abdominal pain in the infants may be caused by some surgical problems.

Inquiry of urination and defecation

Inquiry of urination and defecation includes the frequency, nature and colour of urine and stool. Frequent,loose or sticky stool is a morbid manifestation. Clear profuse urine and night urination indicate asthenia of kidney yang. Frequent urination with occasional pain indicates downward migration of damp heat, such as heat stranguria. Dripping urination with stabbing pain or sandy stones is called stony stranguria.
 
Inquiry of sleep
     
Normally the infants are quiet in sleep. And the  younger the infants are, the longer the sleeping time is.Lethargic sleep and somnolence are usually caused by invasion of pathogenic factors into the pericardium or phlegm clouding the upper orifices in febrile diseases. Restless sleep in rickets and oxyuriasis are accompanied by restlessness and night sweat in the former and anal pruritus in the latter.

Inquiry of age

A number of infantile diseases are related to age, such as tetanus neonatorium, neonatal jaundice, bleeding of the umbilicus and umbilical sore often seen among the neonatal within one week after birth; thrush, umbilical  hernia and night crying usually seen among the nursing infants; enuresis frequently seen among the infants under the age of five.

Inquiry of personal history

Inquiry of personal history includes birth history, feeding history, growth and physical development history. Birth history includes times of pregnancy and delivery,whether the delivery is full term, eutocia or dystocia, whether there is the experience of abortion, the style, place and condition of delivery as well as the nutrition and health of the mother during pregnancy. Feeding history includes feeding method, supplementary food, weaning and conditions after weaning. For the elder infants, the inquiry should include habit of taking food and appetite.

Developmenal history includes physical development and mental development, such as the time of being able to sit, stand, speak and walk as well as tooth eruption and closure of fontanel. As to the children of school age, the inquiry extends to cover the progress of study and inference of the development of intelligence.

Inquiry of vaccination history
    
Inquiry of vaccination history means to ask the parents whether they have applied for vaccination card from the local medical unit after the birth of their infants. Preventive vaccination includes BCG vaccine and live attenuated measles virus vaccine as well as whooping cough, diphtheria, tetanus, encephalitis B, epidemic cerebrospinal meningitis, typhoid fever and paratyphoid, etc.. The vaccination age and reactions should be well recorded.

History of family hereditary diseases
      
The occurrence of many diseases is related to  hereditary factors. So the health of the family members and directly-related members should be inquired to see if  there is family hereditary diseases such as bronchial asthma, haemophilia and hypophrenia as well as consanguine ous marriage.

Feeling Pulse and palpation

Feeling pulse
   
Feeling pulse in diagnosis of the infants is known as one finger touching the three portions of the pulse. That is to say, the doctor uses his or her thumb or index finger to press the three portions of Cun, Guan and Chi to distinguish the variations of pulse under light, moderate and heavy pressure of the finger. The basic pulse conditions of the infants are floating, sinking, slow, rapid, forceful and forceless ones which can be used to differentiate the exterior, interior, cold, heat, sthenia and asthenia of diseases.

Palpation
    
Palpation includes the pressure and palpation of the fontanel, neck, armpit, limbs, skin, chest and abdomen, especially the fontanel and abdomen.
 
Examination of the fontanel should focus on the closure time, size, depression and bulge of the fontanel.Premature closure of the anterior fontanel and small head usually indicate microcephaly; retarded closure of the fontanel with wide fissure is called metopism; depression of the fontanel is often caused by collapse of the gastrosplenic qi or dehydration due to over purgation; bulge of the fontanel accompanied by high fever, vomiting and stiff neck is usually due to accumulation of pathogenic heat and endogenous liver wind. In examining the abdomen of the in-fants, the temperature of the doctor's hand should be similar to that of the infantile skin. In the examination, the doctor should pay attention to the facial expressions of the infants. Usually palpation of the abdomen should start from the lower side of the abdomen on the left side. If there is abdominal pain, palpation should start from the region without pain to avoid tension of the muscles. Normally the skin of the infantile abdomen is soft, warm and painless under pressure. Abdominal pain with preference to pressure and alleviation under pressure is usually of asthenic cold syndrome; unpalpable abdominal pain or abdominal pain aggravated under pressure is often due to internal stagnation of sthenic pathogenic factors, or ascariasis, or dyspepsia, or retention of dryness in the intestine. Flatulence of the abdomen like tympanites is usually due to stagnation of qi; migratory dull sound under percussion often indicates ascites.

Tags: TCM Pediatrics Essentials Diasnosis

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