EXAMINATION OF RESPIRATORY SYSTEM AND ITS REPRESENTATION IN KNERR REPERTORY

Abstract:

Ø  Importance of physical / clinical examination in clinical practice.

Ø  Importance of knerr’s repertory

Ø  Importance of clinical examination finding in prescription.

An old adage claims that “if you listen (exam) to patients, they will eventually tell you what is wrong”. A physical examination, medical examination, or clinical examination (more commonly referred to as a check-up), is the process by which a medical practitioner examines the body of a patient for any possible signs or symptoms of a medical condition. Four actions are taught as the basis of physical examination: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen). Knerr repertory, in spite of its vast information, it is one of the repertory which is not been adequately used by our profession in their clinical practice. In this article let’s discuss about the clinical examination findings of respiratory system and its representation in knerr repertory.

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Keywords: Physical examination, Knerr’s repertory, Respiratory system, Diagnosis.

Introduction:

Diseases of the respiratory system account for up to a third of deaths in most countries and for a major proportion of visits to the doctor and time away from work or school. As with every aspect of diagnosis in medicine, the key to success is a clear and carefully recorded history; symptoms may be trivial or extremely distressing, but either may indicate serious and life threatening disease. ⁽¹⁾

Knerr repertory:

“Repertory of Hering’s Guiding Symptoms of Our Materia medica” –by Calvin Brobst Knerr is one among the Puritan repertories. In this repertory there are 48 chapters, arranged in Hahnemannian (Anatomical) schema. In this repertory, symptoms are arranged almost in its original form without much change. This repertory is based on „Hering‟s guiding symptoms of our Materia-medica‟. Knerr used the same symbols and signs as given in Hering‟s Guiding Symptoms. ⁽²⁾

Homoeopathic view on Importance of Examination to Cure

Dr. J.T. Kent asserted, “If you neglect making a careful examination, the patient will be the first sufferer, but in the end you yourself will suffer from it and homoeopathy also. ⁽³⁾

Sometimes it is said by homoeopaths that the study of pathology is not neces­sary yet Hahnemann’s writings represent the most advanced pathological system in medicine. If the homoeopath has no idea of what the patient is suffering, how can they find a remedy, manage the case, and advise the patient on their condition? It would be more accurate to say, as Hahnemann did, that orthodox pathology with its lack of integrated symptomatology, rigid metabolic concepts, and reductionist disease names is of no help to the homoeopath. Technically speaking, symptoms are those things stated by the patient and signs are those things observed by the examiner. The physical examination is an integral part of the homoeopathic interview ⁽⁴⁾

According to Boenninghausen “the examination of the parts affected is most necessary and most required when the whole to which they belong is larger; it will be conceded from the allopathic side that the closer delimitation of the part affected, even though it may be of moment in the completion of the diagnosis, no allopathic materia medica gives any information that the one remedy, eg. Corresponds more to the anterior or posterior lobe of the liver, more to the upper or the lower part of the lungs, on the right or the left side, according to which the choice of the remedy may be made. Even if we homoeopaths do not as yet know this as to all remedies, we do know it with respect to many of them, and for what is lacking we find a substitute in other sings, since, as is well known, all of these correspond to the remedy to be selected, at least they must not be opposed to it. Thence it may be seen that these new interventions, the value of which I am not in any way inclined to undervalue, have far less value in a therapeutics direction than in prognosis, when they show the extent and dangerous nature of the malady.” ⁽⁵⁾

In aphorism 90 Hahnemann mentioned “When the physician has finished writing down these particulars, he then makes a note of what he himself observes in the patient1, and ascertains how much of that was peculiar to the patient in his healthy state.”

In footnote of aphorism 90- “For example, how the patient behaved during the visit……… what effort did he make to raise himself? and anything else in him that may strike the physician as being remarkable.” ⁽⁶⁾

According to Stuart close, it is taken for granted that the physical examination of a patient will be made thoroughly and systematically also and the findings added to the record. ⁽⁷⁾

Examination of Respiratory System

Despite advances in modern medical technology, a thorough clinical history and examination are fundamental to respiratory medicine ⁽⁸⁾

Inspection	Palpation	Percussion	Auscultation
A. Shape of chest B. Respiratory Movements ·         Respiratory rate ·         Rhythm ·         Character ·         Accessory muscles of respiration ·         Inter-costal retraction/fullness C. Mediastinum ·         Trailes sign ·         Apex impulse D. Miscellaneous ·         Scars, sinuses ·         Pulsations ·         Dilated veins ·         Shiny skin over lower chest	A. Findings of inspection confirmed including Chest Movements B. Mediastinum ·         Trachea ·         Apex beat C. Tactile vocal fremitus: TVF D. Miscellaneous ·         Tenderness over lower inter costal spaces. ·         Other vibrations: Palpable rates, rhonchi, rub	A. Anteriorly ·         Clavicular percussion ·         Intercostal resonance ·         Liver dullness Cardiac dullness ·          Shifting dullness ·         Percussion B. Posteriorly ·         Supra-scapular ·         Inter-scapular ·         Infra-scapular C. In Axilla ·         Axillary ·         Infra axillary	A. Breath Sounds ·         Normal or Diminished ·         Type: Vesicular, bronchial or vesicular with prolonged expiration B. Foreign Sounds: Rales, rhonchi or rub C. Vocal Resonance D. Miscellaneous ·         Bronchophony ·         Egophony ·         Whispering pectoriloquy ·         Succussion splash ·         Coin test ·         Post-tussive suction ·         Post-tussive rales

Table.1.Respiratory system examination ⁽⁹⁾

Rubrics from Knerr Repertory ⁽¹⁰⁾

INSPECTION

RESPIRATION

Ø  Breathing, quick rapid (accelerated hurried) 730,731p.

Ø  Breathing ,quick rapid (accelerated hurried) -  In bronchitis-730p

Ø  Breathing ,quick rapid, (accelerated hurried) -  In pneumonia-731p

Ø  Breathing ,quick rapid, (accelerated hurried) -- In pleuro pneumonia -731p

Ø  Breathing, quick rapid, (accelerated hurried) - Fifty a minute in pneumonia-731p.  

Ø  Dyspnea ,cyanosis 735p

Ø  Inspiration, chest- thorax not distended -739p

Ø  Inspiration forcible -740p

      VOICE AND LARYNX TRACHEA AND BRONCHIA – Voice hoarse 716p

COUGH AND EXPECTORATION

Ø  Cough with emaciation -751p

Ø  Cough with haemoptysis-753p

OUTER CHEST  

Ø  Barrel shaped 850p

Ø  Blue 850p

Ø  Capillary network marbled appearance 850p

Ø  Chicken breast 850p

Ø  Flat 850p

Ø  Narrow 850p

Ø  Rachitic; deformity in costa sternal region 850p

Ø  Sunken 850p

Ø  Veins 852p.

Ø  Fistulous opening -851p

Ø  Ulcer   852p

Ø  Swelling 851p

NECK AND BACK- neck veins distended in inflammation of Lungs ⁽¹⁰⁾

PALPATION

HEART PULSE AND CIRCULATION- heartbeat, excited, small rapid pulse (pneumonia)   825p

RESPIRATION – Inspiration, chest- thorax not distended 739p

INNER CHEST AND LUNGS,

Ø  Inner chest, dropsy (hydrothorax):with oedema of hands and feet 787p

Ø  Lungs auscultation sounds Vocal fremitus increased (pneumonia) 807p ⁽¹⁰⁾

PERCUSSION

INNER CHEST AND LUNGS

Ø  Lungs percussion sounds –dull 812p

Ø  Lungs percussion sounds- dull as a board from apex to axillary border of pectoralis major in front and to middle scapula behind(phthisis) 812p

Ø  Lungs percussion sounds-  dull over lower half of right in asthma 812p

Ø  Lungs percussion sounds- dull circle size of palm of hand  812p

Ø  Lungs percussion sounds- dull in left clavicle 812p

Ø  Lungs percussion sounds- dull in dropsy of chest 812p

Ø  Lungs percussion sounds- dull in heart disease 812p

Ø  Lungs percussion sounds- dull in upper left 812p.

Ø  Lungs percussion sounds- dull in in left lobe, down in third intercostal space 812p

Ø  Lungs percussion sounds- dull in left infra clavicular region sensitive to touch 812p

Ø  Lungs percussion sounds- dull beneath left clavicle 812p

Ø  Lungs percussion sounds- dull over apices in pulmonary diseases 812p

Ø  Lungs percussion sounds- empty hollow in right side  812p

Ø  Lungs percussion sounds- want of normal resonance on left side 812p

Ø  Lungs percussion sounds-tympanitic in edema of lungs 812p

Ø  Lungs percussion sounds- tympanitic on left side, posteriorly as far as 4^th rib and from 5^th rib downward , dull (pneumonia) 812p

Ø  Tympanitic right side up to 3^rd rib behind and below 812p

Ø  Tympanitic on sides, in tuberculosis 812p. ⁽¹⁰⁾

Auscultation

VOICE AND LARYNX, TRACHEA AND BRONCHIA- BRONCHIA MUCOUS

Ø  Rales, when drawing a long breath-705p

Ø  Rales, in bronchitis 705p

Ø  Rales, coarse along larger, during remission of asthmatic Breathing-705p

Ø  Almost continuous rales 705p

Ø  Heavy rales in left, with indications of breaking down of parenchymatous structure and cavernous lesions (phthisis) 705p

Ø  Rales, in pleuro-pneumonia biliosa 705p

Ø  Rales in upper 705p

INNER CHEST AND LUNGS-

Ø  Lungs ,rales (rattling) 814

Ø  Lungs rales, over anterior surface of right (phthisis) 814

Ø  Lungs rales, continual 814p.

Ø  Lungs rales, Crepitant 814p

Ø  Lungs rales, coarse Crepitant in spot behind left 5^th rib 814p

Ø  Lungs rales, coarse in oedema of Lungs 814p

Ø  Lungs rales, fine 814p

Ø  Lungs rales, moist 814p

Ø  Lungs auscultation sounds - Aegophony, right side towards upper part (pleurisy) 806p

Ø  Lungs auscultation sounds -Aegophony in pneumonia 806p

Ø  Lungs auscultation sounds -Amphoric in tuberculosis 806p

Ø  Lungs auscultation sounds -One of the apices audibly diseased 806p.

Ø  Lungs auscultation sounds ,Bronchial 806p

Ø  Lungs auscultation sounds -Bronchial indistinct with numerous rales, partly dry, partly moist, with dull percussion over lower portion of thorax on right side 806p

Ø  Lungs auscultation sounds Bronchial, from 5^th rib downwards, in pneumonia 806p

Ø  Lungs auscultation sounds Bronchial, on right side, in phthisis 806p

Ø  Lungs auscultation sounds Bronchial, in right, supra scapular region (phthisis) 806p

Ø  Lungs auscultation sounds Bronchial, in right side (pleuro- pneumonia biliosa) 806p

Ø  Lungs auscultation sounds Bronchial, strong in front, right side, above and behind (pneumonia) 806p

Ø  Lungs auscultation sounds Bronchial, in tuberculosis,806p

Ø  Lungs auscultation sounds Bronchial, upper half (asthma) 806p

Ø  Lungs auscultation sounds Camphoric sounds in the right 806p

Ø  Lungs auscultation sounds -Creaking lethargy noise, over middle and lower third of right (pneumonia) 806p

Ø  Lungs auscultation sounds Crepitant rales (pleuro-pneumonia biliosa) 806p

Ø  Lungs auscultation sounds -Crepitation in bilateral croupous pneumonia,806p

Ø  Lungs auscultation sounds -Crepitation, coarse beneath left clavicle (hemorrhagic phthisis) 806p

Ø  Lungs auscultation sounds Crepitation coarse, below border of pectoralis major, and around posteriorly to back of Lungs (haemorrhagic phthisis) 806p

Ø  Lungs auscultation sounds Crepitation, coarse, in phthisis 806p

Ø  Lungs auscultation sounds Crepitation, coarse, posteriorly about center (phthisis) 806p

Ø  Lungs auscultation sounds Crepitation, dry, over both, veiled by coexisting coarse bronchial rales (measles) 806p

Ø  Lungs auscultation sounds Crepitation, fine, in broncho- pneumonia, 806p

Ø  Lungs auscultation sounds Crepitation, in left (pneumonia) 806p

Ø  Lungs auscultation sounds Crepitation in both lower lobes (pneumonia) 806p

Ø  Lungs auscultation sounds Crepitation, in pneumonia 806p

Ø  Lungs auscultation sounds Crepitation, posteriorly, in right lung from forced inspiration 806p

Ø  Lungs auscultation sounds Crepitation in right supra scapular region (phthisis) 806p

Ø  Lungs auscultation sounds On right side, superiorly and posteriorly feeble, but distinct crepitation in upper part of chest, respiration sharp and expiratory murmur indistinct (pneumonia) 806p

Ø  Lungs auscultation sounds Harsh, in left apex (phthisis) 806p

Ø  Lungs auscultation sounds Weak rattling murmur in apices, worse in right (consumption) 806p

Ø  Lungs auscultation sounds -Weak respiratory murmur in right side, in nipple line in 5^th intercostal space (bronchial catarrh) 806p

Ø  Lungs auscultation sounds Purring, in bronchial catarrh, 806p

Ø  Lungs auscultation sounds -Purring with cough 806p

Ø  Lungs auscultation sounds Consonating rales at 4^th rib (pneumonia) -806p

Ø  Lungs auscultation sounds Sub-crepitant rales over summit of right,806p

Ø  Lungs auscultation sounds Small crepitating rales in base, posteriorly (infantile pneumonia) 806p

Ø  Lungs auscultation sounds Fine vesicular rales at left apex 806p

Ø  Lungs auscultation sounds -Ronchi, dry (phthisis) 807p       

Ø  Lungs auscultation sounds Ronchi, sibilant, wheezing 807p

Ø  Lungs auscultation sounds Sibilant, all over, especially lower right lobe (pneumonia) 807p

Ø  Lungs auscultation sounds -Lower snoring, as if through a tube (bilateral croupous pneumonia) 807p

Ø  Lungs auscultation sounds Vesicular murmur absent in dropsy of chest 807p

Ø  Lungs auscultation sounds Vesicular murmur absent in left 807p

Ø  Lungs auscultation sounds Vesicular murmur absent in posterior half of left 807p

Ø  Lungs auscultation sounds Vesicular murmur absent in pleuritis with plastic exudation 807p

Ø  Lungs auscultation sounds Vesicular murmur absent in pneumonia 807p

Ø  Lungs auscultation sounds Vesicular murmur absent at top of right 807p

Ø  Lungs auscultation sounds Vesicular murmur absent in upper part of superior lobe 807p

Ø  Lungs auscultation sounds Vesicular murmur dry in upper part (asthma)  807p

Ø  Lungs auscultation sounds Vesicular murmur feeble 807p

Ø  Lungs auscultation sounds -Vesicular murmur feeble in cardiac dropsy 807p

Ø  Lungs auscultation sounds Vesicular murmur almost inaudible 807p

Ø  Lungs auscultation sounds -Vesicular murmur indistinct, especially in lower lobe 807p

Ø  Lungs auscultation sounds Vesicular murmur indistinct in several places (asthma) 807p

Ø  Lungs auscultation sounds  Weak vesicular Breathing (oedema of Lungs) 807p

Ø  Lungs auscultation sounds -Increased vocal resonance of right.807p ⁽¹⁰⁾

RESPIRATION  

Ø  Breathing, rattling 731p

Ø  Breathing, rattling -Fine rales 731p

Ø  Breathing, rattling -In left chest 731p

Ø  Breathing quick, loud mucous rales- 730P

COUGH AND EXPECTORATION- Moist rales over chest (endocarditis) 759p ⁽¹⁰⁾

Conclusion:

A proper choice of investigations guided by logical clinical decision-making after integrating the clinical history and physical exam in differential diagnosis is imperative for timely diagnosis to enhance patient safety. ⁽¹¹⁾

Knerr repertory is the most useful but the most neglected repertory in our clinical practice. It is evident that knerr repertory is very useful in our daily practice provided the case presented with characteristic symptoms, concomitant symptom, deep pathological symptom, or with diagnostic symptom. “True it is, that the careful observer alone can become a true healer of disease.”