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 endurancestrength of a person
Existence of mindspecific perception
Qualitydeed/action
Agestage of life
Habitatlikes & dislikes
Etiological factorsdisease
Degree of vitiation of doshasprovocative factors
Deathfatal 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 soundsS1,S2
Extra SoundsS3,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 soundsS1,S2
Extra SoundsS3,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
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Trividha Pareeksha -prepared by
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