Trividha Pareeksha -prepared by

Trividha Pareeksha -prepared by
-Dr.Jeejo Chandran.O, 1st yr MD Panchakarma
Trividha Pareeksha
Derivation:
(Parithaha eeksha)

The word Parithaha means “from all the directions” and eeksha means “observation”.

Therefore Pareeksha is “observation from all the directions”.

Introduction
Scientific & holistic approach towards diagnosing diseases can be seen from the ancient period
Ayurvedic clinical examination includes

1.Roga Pareeksha-Diagnosis of the diseases
2.Rogi Pareeksha-Examination of the patient

Trivida pareeksha- comprises the aspects of Roga and Rogi pareeksha

Classifications of Trividha Pareeksha

Aptopadesa
Prakthyasha
Anumana



Charaka&Vagbhata
Darsana
Sparsana
Prasna

Aptopadesa
Vedic literature written by enlightened people with divine power which guides us on
Aggravating factors , dosha involvement, manifestation of diseases ,acute,chronic,fatal description , location in sarira,mana,or both
Description about pain , association with certain smell ,taste , colour ,touch and sound
Factors affecting treatment ,its principle,avoidances etc

Prakthyasha
Examination by sensory organs
Feelings like happiness ,desire etc mostly perceived by Atma through Indriyas
Different body conditions assessed by using Indriyas
Most of the sense organs of a patient can be checked by a physicians’ careful direct examination except taste and smell

Charaka
Aptopadesa
Prakthyasha
Anumana


Trividha pareeksha

Trividha pareeksha

Inference made assumption as
Power of agni  digestion and metabolism
Exercise endurancestrength of a person
Existence of mindspecific perception
Qualitydeed/action
Agestage of life
Habitatlikes & dislikes
Etiological factorsdisease
Degree of vitiation of doshasprovocative factors
Deathfatal signs






Anumana

Darsana or inspection

Definition:Thorough and unhurried visualisation/realisation
External signs and Gross deviations
Examples unlimited—age,colour,structure,shape,size etc
Helps in detecting many conditions like,visible mass,swelling,discoloration of skin ,eyes,manner of gait,speech etc
Not only limited to visual examination,but also realising auditory and olfactory factors


As far as possible,it should be done in sunlight because the inference drawn in artificial light can be wrong.
The place should be clean and calm.The patient should be relaxed and at ease.
Examination of the patient should be the only concern of the physician.
Assessment should be done from head to toe.

Precautions in Inspection

Determination of painful areas,qualify the pain felt
Locate three dimensional coordinates of anatomial landmarks
By using the s ensation of touch
Pulse,Sense of hotness,coldness,hardness,smoothness etc
Size and shape or firmness or location of something



Sparsana or Palpation

Interrogation about the subjective feelings like pain,sensation,feelings like happiness and distress
Valuable information regarding aetiology, nature of pain,satmya and agnibala
Medical history which can be mostly known only through an effective communication
An experienced physician carefully evaluates the patients statements on medical background

Prasna

Percussion-Dr.Lepold Auenbruggers Austrian physician invented percussion in 1744.Though the history of percussion goes 1000 yrs back to Ib sina ,a persian Unani laureate who described it in his “Book of healing”

Auscultation-Dr Rene Lennec French professor of medicine invented stethescope in 1816.Though the history of auscultation goes way back to ancient Greece


Other techniques included

Listening to the internal body sounds-mainly pulmonary, cardiac and bowel sounds
Immediate
Mediate
Doppler
Doppler sensitivity of 84% against 58% for stethescope in aortic regurgitation.
Also for detecting bruits-arterial narrowing, measuring liver span

Auscultation

BOWEL SOUNDS
Hypoactive
Hyperactive
Missing


Heart Sounds
Normal soundsS1,S2
Extra SoundsS3,S4
Murmurs,
adventitious sounds
gallop rhythm
Rub
Venous hum etc


Normal Breath sounds
Bronchial sounds
Vesicular Sounds
Decreased/absent
Abnormal
Rales-crackles
Ronchi-snoring like
Wheezes-high pitch,musical



Breath Sounds

Auscultation skills

Mnemonic
6am-7pm

Starting from the space above clavicle,down along
mid clavicular line on both sides alternately upto the level of nipples then laterally towards mid axillary line to the sixth and seventh intercostal space


Where to place stethescope?
Breath sounds

Mnemonic
aptm2245

S3,S4
Early,Late
Diastolic

S2

S1

Starting from right second intercostal space near sternum to left
intercostal space,continue down with left third and fourth intercostal
space a to the fifth intercostal space where apex beat is usually heard

Where to place stethescope?
Heart Sounds

Method of tapping on thorax or abdomen to determine the underlying structure
Direct—uses one or only two fingers
Indirect– uses the middle finger
4 types-
Resonant-normal lung-loud,low pitch,long
hyper resonant-gastric air buble-loud,musical timbre
stony dull –thigh-soft,high pitch,short
Dull-liver-medium intensity,pitch and duration


Percussion

Considered as a part of hidden medical curriculum

Talking Part has 3 basic parts
Information Gathering
Rapport Building
Information Sharing


Doctor-patient interaction/
Bedside Manners 1.Talking part

Importance of History taking

Information Gathering is not mere questioning/download, but collecting relevent history in a conversation manner.What pt thinks about the disease,his/her anxiety,previous reports,informed consent etc
Rapport building by talking in an empathising manner with the patient
Information sharing includes medical condition,medications,risks,and a “teach back” process to double check.

Doctor-patient interaction
1.Talking part

General Examination: Ht,Wt,BMI,gait,palor clubbing cyanosis,jaundice,lymphnode enlargement dependent oedema,(breast,thyroid,)

Systemic examination:NS,CVS,RS other relevent systems
Inspection,palpation,percussion,auscultation

2.Physical examn part


Mouth-soft palate ,tongue, cranial nerves
Neck-Thyroid
Lungs-back of chest practically used
Heart-Palpation-point of Maximum Impulse
Auscultation-Lub-dub –closing of valves
Abdomen-palpation-4 quadrants corresponds anatomical structures ex: Rt quadrant –liver,gallbladder


Doctor-patient interaction
2.Physical examn part

BOWEL SOUNDS
Hypoactive
Hyperactive
Missing


Heart Sounds
Normal soundsS1,S2
Extra SoundsS3,S4
Murmurs,
adventitious sounds
gallop rhythm
Rub
Venous hum etc

Normal Breath sounds
Bronchial sounds
Vesicular Sounds
Decreased/absent
Abnormal
Rales-crackles
Ronchi-snoring like
Wheezes-hig pitch,musical



Breath Sounds

Auscultation skills

Mnemonic
6am-7pm

Starting from the space above clavicle,down along
mid clavicular line on both sides alternately upto the level of nipples then laterally towards mid axillary line to the sixth and seventh intercostal space


Where to place stethescope?
Breath sounds

Mnemonic
aptm2245

S3,S4
Early,Late
Diastolic

S2

S1

Method of tapping on thorax or abdomen to determine the underlying structure
Direct—uses one or only two fingers
Indirect– uses the middle finger
4 types-
Resonant-normal lung-loud,low pitch,long
hyper resonant-gastric air buble-loud,musical timbre
stony dull –thigh-soft,high pitch,short
Dull-liver-medium intensity,pitch and duration


Percussion

Considered as a part of hidden medical curriculum

Talking Part has 3 basic parts
Information Gathering
Rapport Building
Information Sharing


Doctor-patient interaction/
Bedside Manners 1.Talking part

Mouth-soft palate ,tongue, cranial nerves
Neck-Thyroid
Lungs-back of chest practically used
Heart-Palpation-point of Maximum Impulse
Auscultation-Lub-dub –closing of valves
Abdomen-palpation-4 quadrants corresponds anatomical structures ex: Rt quadrant –liver,gallbladder


Doctor-patient interaction
2.Physical examn part

Three fold approach helps to cover the diagnosis as well as prognosis of diseases
By that it envisages that each disease will be presenting almost uniquely in each patient
Advocates physician’s sharp senses and physical presence
Their order signifies their relative reliability
Limitations include lack of importance given to the other factors affecting diseases




Discussion

Trividha Pareeksha comprises the core of clinical examination

Both the patient and the disease are assessed

First of its kind and pretty much authentically followed these days


Conclusion

Where to place stethescope?Breath sounds
Mnemonic
aptm2245

Starting from right second intercostal space near sternum to left
intercostal space,continue down with left third and fourth intercostal
space a to the fifth intercostal space where apex beat is usually heard

S3,S4
Early,Late
Diastolic

S2

S1

Where to place stethescope?
Heart Sounds

Importance of History taking

Mouth-soft palate ,tongue, cranial nerves
Neck-Thyroid
Lungs-back of chest practically used
Heart-Palpation-point of Maximum Impulse
Auscultation-Lub-dub –closing of valves
Abdomen-palpation-4 quadrants corresponds anatomical structures ex: Rt quadrant –liver,gallbladder


Doctor-patient interaction
2.Physical examn part

Listening to the internal body sounds-mainly pulmonary, cardiac and bowel sounds
Immediate
Mediate
Doppler
Doppler sensitivity of 84% against 58% for stethescope in aortic regurgitation.
Also for detecting bruits-arterial narrowing, measuring liver span

Auscultation

Agnivesha Jwara nidanam:Agnivesha’s Charaka Samhita: R.K. Sharma, Bhagwan Dash: Edition-reprint:2001: Chowkhamba Sanskrit Series Office, Varanasi : Nidana Sthana
Agnivesha Rogabishagjithiyam:Agnivesha’s Charaka Samhita: R.K. Sharma, Bhagwan Dash: Edition-reprint:2001: Chowkhamba Sanskrit Series Office, Varanasi : vimana sthanam
Agnivesha Trividharogavishashavignyaneeyam:Agnivesha’s Charaka Samhita: R.K. Sharma, Bhagwan Dash: Edition-reprint:2001: Chowkhamba Sanskrit Series Office, Varanasi,vimana sthana
Agnivesha Dwivraniyachikitsa:Agnivesha’s Charaka Samhita: R.K. Sharma, Bhagwan Dash: Edition-reprint:2001: Chowkhamba Sanskrit Series Office, Varanasi : chikitsa sthana
Agnivesha Tishraishniyamadhyayam:Agnivesha’s Charaka Samhita: R.K. Sharma, Bhagwan Dash: Edition-reprint:2001: Chowkhamba Sanskrit Series Office, Varanasi : Sutra Sthana
Ashtanga samgraha ,suthra sthana.
Susruta samhita, sutra sthana.
Clinical methods in ayurveda,Srikantamurthy.
Roga vinjana and vikriti vinjana .
Rogi pareeksha vidhi – Acharya P. V. Sharma
Kayachikitsa - Prof.Ramaharsha Sing
Shareera kriya – Ranade & Deshpande.
http://www.practicalclinicalskills.com/heart-lung-sounds-reference-guide.aspx


Referrances

Three fold approach helps to cover the diagnosis as well as prognosis of diseases
By that it envisages that each disease will be presenting almost uniquely in each patient
Advocates physician’s sharp senses and physical presence
Their order signifies their relative reliability
Limitations include lack of importance given to the other factors affecting diseases




Discussion