Asking the Right Questions by M.M. Van Benschoten, OMD

Asking the Right Questions by M.M. Van Benschoten, OMD

Questioning the patient is an essential part of the four diagnostic methods in TCM. In complex cases, asking the right questions and paying close attention to minor symptoms can help to determine the location of pathogenic factors and direct appropriate treatment. A complete history of previous illnesses, surgeries, and hospitalizations with a review of current symptoms provide the basis for accurate diagnosis. Review of laboratory test results, imaging reports, current pharmaceuticals, and nutritional supplements must be included.

Repeated questioning about history, diet, and environment will reveal information that was forgotten or ignored for years. A good example is an elderly patient with severe multiple food allergies, eczema, hip pain, and weight loss who recalls the flooded basement in her home after 12 office visits and three years of treatment. The new onset of daily headaches suggested indoor mold exposure, although the patient denied any water damage in her home on the initial examination.

Getting to the roots of chronic illness requires constant and persistent questioning to uncover the origins of processes that began many months or years ago. Continued inquiry into the patient’s diet and environmental conditions assists the process of recovery through identification and elimination of interfering factors. When clinical improvement is followed by relapses, the cause often stems from errors in diet or new environmental exposures.

Asking when the last serving of dairy, refined sugar, or junk food was consumed is the best way to get accurate information, as patients will deny poor food choices when questioned in a general way. Are you eating dairy or sugar? No. When was the last time you had milk, cheese, or ice cream? Yesterday. The person who claims to be dairy and gluten free on the first visit will admit to eating those offending foods on a regular basis when asked more specifically in a temporal context. Dairy products and sugar activate opioid receptors and the addictive nature of these foods insure frequent relapses with increased inflammation and new infections.

The following series of questions are an expansion of the classical TCM methods, with considerations for contemporary lifestyles and biomedical interventions.

Fever, chills, night sweats

Temperature changes of sudden onset are most often due to pathogenic factors invading the lungs in the absence of other symptoms. In the early stage of infection there may be only chill, fever, and fatigue. Urinary tract infections can also be a source of acute fevers. Patients with constant cold sensations have circulatory problems or thyroid dysfunction. Constant heat sensations without chill or sweats are due to low level infections or autoimmune processes. Menopausal hot flashes may be differentiated from respiratory infection by the absence of cough, palpitations, fatigue, and shortness of breath. Night sweats with fatigue and palpitations are common symptoms of low level respiratory infections.

Headache, head pressure, sore throat, ear pain

Sinus infections due to bacteria, virus, and fungi are the most common cause for these symptoms. Drainage from the sinuses can induce cough, ear ache, esophageal reflux, stomach pain, and hypoglycemia. Alternating headache and digestive upset are a strong indicator of chronic sinusitis. Tooth pain in the upper jaw without dental pathology can be from sinus inflammation. Daily headaches for several months or years are often related to fungal infections and indoor mold exposure.

Hearing loss, tinnitus, dizziness, vertigo

Ear infections in adults may be painless, with the primary symptoms being light headed sensations, balance disorders, vertigo, tinnitus, and hearing loss. Slight pressure or a sensation of fullness in the ear may be accompanied by itching or discharge.

Nasal congestion, nosebleeds, post nasal drip, sneezing, snoring

Nosebleeds suggest the presence of chronic strep infection of the nasal passages and sinuses. Snoring comes from blocked nasal passages and post nasal drip irritating the nasopharynx. Sleep apnea from chronic respiratory infections interfering with nerve transmission contribute to chronic fatigue and daytime sleepiness.

Vision blurred, double, weak

Disturbances of sight may be induced by sinus and dental infections because of their close proximity to the eyes. Glaucoma and macular degeneration originate in fibrotic reactions to bacterial infections of the sinuses, periodontal disease, or the effects of air pollution. Allergic responses to poor indoor air quality may develop into autoimmune disorders such as uveitis, blepharitis, and blepharospasm.

Dental cleaning, last dental work, filling, crown, root canal, bleeding gums

Oral bacteria that cause periodontal disease are implicated in cardiovascular damage and risk of pancreatic cancer. Brain inflammation from dental infections may be a factor in memory loss, mood disorder, or dementia. Mercury leakage from decayed amalgam fillings cause multidrug resistance in bacteria and induce autoimmune central nervous system, joint, and kidney disease. Professional dental cleaning should be every six months. Previous amalgam removal and nutritional detoxification measures often fail to address the residual autoimmune activity after decades of mercury exposure.

Cough, chest pain, shortness of breath, phlegm

Respiratory infections are the most common origin of fatigue, as oxygenation of the blood is essential to energy production. In the absence of cough, dyspnea, or phlegm, symptoms of night sweats, palpitations, upper back or joint pain, and insomnia are common with low level lung infection. After multiple courses of antibiotics, resistant organisms can persist in the lung causing constant fatigue and inflammation. Lack of phlegm production relates to dehydration and inadequate immune response requiring increased water intake of 1.5 liters per day.

Palpitations, rapid or irregular heartbeat

Arrhythmias may be the most noticeable symptom of respiratory infection when cough is absent, because the infection in limited to the lung without involvement of the bronchi. After infection, toxic chemical exposures from jet fuel, paint, solvents, cleaning products can contribute to negative effects on cardiac function. The direct anatomical connection between lung and heart insures that inflammatory changes in lung tissue can effect cardiac function.

Appetite, thirst, taste, smell, weight gain/loss

Increased or decreased appetite can be the result of sinus drainage causing irritation of the small intestine. Diminished sense of smell or abnormal taste sensations are neurological effects of infections in the sinuses and nasal passages blocking function of the olfactory nerve. Extreme sensitivity to odors is a sign of chemical sensitivity secondary to chronic respiratory infections and toxic environmental exposures. Weight gain can be due to changes in intestinal flora from food poisoning, refined flour/sugar intake, intolerance of microbial contaminants in animal protein, and sedentary lifestyle. Toxins from intestinal bacteria can damage mitochondrial function, interfere with insulin and thyroid hormone receptors, and trigger autoimmune induction of fat cell proliferation.

Nausea, vomiting, diarrhea, blood or mucus in stool

Bacterial contamination of green leafy vegetables, dairy products, and chicken are the most common source of gastrointestinal complaints, hospitalizations, and deaths from food borne illness in the US according to research from the CDC. When headaches are part of the clinical picture, ask about post nasal drip to confirm irritation of the gastrointestinal system from sinus drainage. Excessive hunger or nausea after meals are common patterns for sinus induced gastritis and hypoglycemia. Bleeding and mucus in the stool indicates high levels of inflammation and immune activation with vascular damage. The relationship of dairy products to the incidence of Crohn’s disease and ulcerative colitis may be related to pasteurization resistant bovine mycobacteria.

Constipation, gas, bloating, reflux

Bacterial overgrowth from excessive sugar, white flour, and alcohol intake may induce inflammation of the esophagus and intestines causing reflux, bloating, and constipation. Raw leafy greens, dairy products, and chicken are the most common sources of food borne illness, and for many cases of IBD, the elimination of these foods resolves the condition. Over the past three years our clinical observations indicate a single salad can have immediate negative effects on bowel and immune function. Chronic sinus drainage is often a trigger for GERD, especially in those cases that fail to respond to pharmaceuticals.

Abdominal pain, cramping, spasm

Upper abdominal pain with nausea or reflux is related to the esophagus, stomach, and/or small intestine. In the upper right quadrant, gallbladder dysfunction should be suspect. Lower abdominal pain in the left lower quadrant of the abdomen originates in the descending colon and is usually associated with constipation. Pelvic pain from ovaries, uterus, fallopian tubes, and adhesions may be related to the onset of ovulation and/or menstruation.

Urination pain, frequency, urgency, incontinence, odor, color

Urinary tract infections and interstitial cystitis from translocation of intestinal bacteria triggering autoimmune responses are common clinical presentations. Multiple rounds of antibiotics for UTI result in resistant bacterial overgrowth that can begin the next cycle of infection. A negative urinalysis indicates bacterial colonies are adhering to the bladder, without significant shedding in the urine. After multiple rounds of infection and antibiotics, the immune system may fail to differentiate the bladder from the bacteria adherent to the mucus membrane, initiating a constant inflammatory response to normal flora. Incontinence and frequency may be the principal symptoms of infections in elderly patients, as immune responses are insufficient to cause significant pain.

Muscle and joint pain, swelling, redness, stiffness

Bacterial and viral infections of the respiratory and digestive systems may induce immune responses that cross react with muscle, joint, bone, cartilage, ligament, and tendon. Dental infections and periodontal disease are also important triggers for joint inflammation. Coffee is linked to rheumatoid arthritis and acute coronary events. Previous automobile accidents, athletic injuries, and falls can induce post traumatic arthritis and degenerative joint disease.

Skin and hair

Skin disorders and hair loss often originate from inflammatory responses to intestinal flora. Chronic urticaria is linked to indoor mold exposures in our clinical experience. Microbial toxins induce antibody responses that cause inflammation of the skin, lymph, and microcirculation with cross reactivity to hormone receptors causing alopecia. Intolerance of testosterone in cows milk is a well documented cause of acne in adolescents.

Sleep, sexual desire, performance

Insomnia due to respiratory infections may be confirmed by symptoms of night sweats, palpitations, and morning phlegm. Lack of sexual desire indicates disturbances of hormone receptors, often a secondary manifestation of immune responses to imbalanced intestinal flora. Inability to get or maintain an erection can be an important first sign of cardiovascular disease and systemic atherosclerosis.

Concentration, memory, mood, anxiety, depression, irritability

Mood disorders with digestive symptoms indicate immune responses to intestinal flora that effect neurotransmitter receptors and synthesis. When anxiety and insomnia are accompanied by respiratory and cardiac symptoms, inflammatory reactions to microbial infections of the lungs and sinuses are often the root cause. Sleep deprivation from emotional stress, overwork, or sensitivity to caffeine can result in increased inflammation of the brain due to upregulation of TNF alpha.

Alcohol, tobacco, parental smoking, coffee

Daily alcohol use can induce gastrointestinal and neurological damage, disturbed sleep patterns, and hormonal imbalances. Arsenic, cadmium, and lead in wines may have cumulative effects on brain and cardiovascular function. Tobacco is a risk factor for cancer, heart attacks, and strokes. Parental smoking exposes children to four times more potential damage than first hand smoking. Coffee is linked to anxiety, insomnia, GERD, risk of acute coronary events, and rheumatoid arthritis. Chronic joint and muscle pain can be initiated by a single cup of coffee on even a monthly basis for the most sensitive individuals. Over one thousand toxic chemicals with carcinogenic and cholesterol raising effects are the byproducts of the coffee roasting process.

Air travel, water damage, remodel, gardening

Exposure to jet fuel, toxic mold, building materials, paint, solvents, soil fungi and bacteria contribute to chronic respiratory, digestive, and neurological illness. Asking specific questions about the onset and relief of symptoms in different environments, better or worse at home, office, or car will unmask this essential component of accurate diagnosis and treatment.

Household cleaning products

Inhalation of chlorine, phenol, and ammonia compounds may cause lung damage and constant rounds of infection. White vinegar is safer than bleach and baking soda should be used instead of chlorinated scouring powder. Products marketed as green may actually contain petrochemical solvents with significant toxic effects.

Carpeting, mattress, pillow, indoor plants

Old carpeting, mattresses, pillows, and indoor potted plants are important sources of bacterial and mold growth inducing respiratory and neurological illness. Autoimmune responses triggered by indoor air quality issues may not respond to any treatment until the offending materials are removed from the living space. Carpet over five years old can double its weight in dirt and mold spores. Memory foam and polyurethane foam pillow and mattress materials can have toxic effects on respiratory, immune, and nervous systems. All pillows grow bacteria and fungi, with feathers and foam growing Acinetobacter and Staphylococcus aureus. Synthetic hypoallergenic polyester pillows should go in the dryer once a week, washing machine once a month, and replaced every six months.

Pets, pest control service

Dogs, cats, hamsters, rabbits, chickens, and horses carry microbial pathogens transmissible to humans. Toxoplasmosis from cat feces, dermanyssus mites from birds and chickens, allergic responses to animal dander induce immune responses with varied effects. Rats, mice, and cockroachs may transmit bacteria into the living space. Pesticide exposures may have negative effects on neuroendocrine and immune systems.

Recreation, occupation, driving

Certain recreational activities can be contributing factors in chronic illness. Running on the street, bicycling in close proximity to traffic, swimming in a public pool are sources of exposure to gasoline, diesel exhaust fumes, and chlorine. Occupations with toxic chemical exposures include artists, auto repair, construction workers, farmers, painters, electricians, air conditioning service, nail salon workers, and hairdressers. Leaking automobile exhaust systems may cause sleepiness while driving and can be a source of fatigue for commuters with long periods in the car. Post traumatic arthritis from athletic injuries and automobile accidents must be considered in chronic pain and neurological conditions.

Exercise, diminished tolerance

In highly trained athletes, the only sign of respiratory tract infection may be reduced exercise tolerance. This will manifest as running out of energy earlier in the workout, or a lack of motivation to start the daily routine. Sedentary lifestyle is a risk factor for many serious illnesses, and may actually shorten lifespan more than smoking. Daily walking should be encouraged for stress and weight control.

Surgical history

Tonsillectomy reflects susceptibility to streptococcal infections, respiratory illness, and a history of multiple courses of antibiotic therapy with negative impact on intestinal flora. Appendectomy, hernia, cholecystectomy relate to inflammatory responses from intestinal bacteria. Ovarian cysts, uterine fibroids, and benign prostatic hypertrophy indicate stimulation of hormone receptors and fibroblast proliferation from antibodies to common bacteria in the GI tract. Joint replacement without a history of trauma relates to chronic autoimmune conditions that target cartilage, tendon, ligament, and bone.

Physical, emotional, sexual trauma

Post traumatic stress disorder is a complex autoimmune process involving neurotransmitters and hormones. Chronic pain and sleep disorders may have their roots in a past illness, traumatic events, or prolonged emotional stress from abusive relationships at home or at work. Memory T cells sensitized to stress induce neurohormonal changes with inflammatory effects on multiple organs and systems.

Current and past pharmaceutical medications, vaccinations

Side effects from prescription drugs are common. Statins may cause severe muscle pain, beginning immediately after initiating treatment, or in some cases many years after tolerating the drugs. Multiple courses of antibiotics for respiratory or urinary tract infections result in pathological intestinal flora with secondary digestive, hormonal, and dermatological manifestations. Antidepressants, antianxiety, pain, and sleep medication may have addictive properties. Any medication can lose effectiveness over time, which is why hypertensive patients must monitor blood pressure at home to confirm good clinical response. When the practitioner suspects pharmaceutical side effects, the patient should contact their MD to discuss modification of dosage or changing medications. The combination of statins, blood pressure medications, proton pump inhibitors, antiinflammatory drugs, sleep and/or anxiety agents is observed in patients with coffee intolerance.

Nutritional supplements

Chronic disease that is not adequately addressed by conventional or alternative medicine may result in patients self prescribing multiple nutritional supplements. When infection and autoimmune responses are the root cause of illness, supplementation may do more damage than good by stimulating growth of pathogens and augmenting inflammatory immune responses. Recent research has associated calcium and high dose B vitamin supplementation with increased cardiac mortality.

Laboratory results and imaging reports

Blood work, urinalysis, X ray, ultrasound, CT, MRI, and PET imaging provide important information for diagnosis. Low RBC and WBC counts can indicate malabsorption or the result of chronic infection and low level inflammation. High cholesterol, triglycerides, LDL, and glucose point to excess intake of animal protein, dairy, sugar, and/or intestinal dysbiosis. Abnormal liver and/or kidney function tests suggest autoimmune responses to toxic intestinal flora or chronic low grade infections. Positive ANA, elevated ESR or sedimentation rate indicate blood stasis from inflammatory responses to chronic infection. The source of inflammation can be identified through subtle symptoms that reveal the locus of pathogenic factors, as in palpitations and night sweats for lung infections, gas and bloating for intestinal dysbiosis, headaches and nosebleeds for sinusitis.

Dietary restrictions

Patients know that certain foods aggravate their symptoms. Childhood dairy intolerance that appears as ear infections and constipation are the beginnings of atherosclerosis, cancer, and diabetes that will be diagnosed later in adulthood. Chronic illness and inflammation are fueled by the microbial contaminants in dairy and animal products. Eliminating white flour, soft drinks, and fruit juices are essential measures to control obesity and diabetes. Cooked food is safer than raw, and soup generates more weight loss than salad. Patients without diagnosed celiac disease or gluten sensitivity may still benefit from avoiding wheat due to the mycotoxin contamination from grain storage. Vegan diets have been demonstrated to have benefits for autoimmune disorders, cardiovascular disease, and cancer inhibition.