Resources and Strategies

The Evidence-Informed Chiropractor

 

History Clue Clusters
for Selected Disorders

 

You just need to look!

It is not uncommon for patients to present with history clues that indicate an underlying problem that is not related to their chief complaint but may influence it.

These history clusters have been identified in the literature and can serve as a guide for screening your patients for conditions including type 2 diabetes, depression, and migraine headache.

Another group of history clusters related to the chief complaint may identify a patient at risk for a more serious disorder.

Following is a brief list of these clusters and the possible underlying disorder.

Type 2 Diabetes
Although, when asked, most doctors would list the polys (i.e. polyuria, polydypsia, and polyphagia) as the primary history clues for diabetes, they do not realize that this is true mainly for type 1 diabetes and later stages of type 2 diabetes.

For type 2 diabetes, the three most common complaints are

  • fatigue
  • numbness and tingling (usually the distal extremities), and
  • vision that changes throughout the day (e.g. blurry then clear)
For females, an additional clue is frequent yeast infections.

American Diabetes Association (ADA). Standards of medical care in diabetes IV. Prevention/delay of type 2 diabetes. Diabetes Care. 2007;30:S7-S8.



Depression
Two common mistakes are assuming the patient will tell you when they feel depressed and that the patient can identify the cause. For a major depressive episode (MDE), neither are always true. Because MDE is due to an imbalance of neurotransmitters, there is often no initiator that the patient can identify.

Although there are a number of well-designed and valid measures for patients with major depression, the top two clues include:
  • anhedonia (i.e. loss of joy in life) and,
  • a depressed mood
These two clues (if both present) are 96% sensitive for major depression. They are only 57% specific, though, requiring mroe questioning.

Whooley MA, Avins AL, Miranda J, Browner WC. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med 1997;12(4)439-445.


These two clues when added to several other indicators represents the best cluster for screening for depression. These are:
  • weight loss
  • sleep disturbance (e.g. early morning awakening)
  • fatigue
  • inability to concentrate or feeling overwhelmed
  • psychomotor retardation or agitation
  • feelings of guilt, worthlessness, or self-reproach
  • suicidal thought or focus on death
This totals nine potential clues which independently are not strong indicators but when 5 out of the 9 clues are present, depression is likely.

It is also important to look for a cluster of complaints which include headache, dizziness, difficulty breathing (without chest pain), and multiple joint pains. Each taken alone is not helpful but when all are present, depression is a possible cause. This cluster represents a characteristic of depressed individuals to somatize. This means that the depression is converted or transformed into "body" complaints that are often musculoskeletal.


Migraine Headache
Migraine headaches are underdiagnosed because associated symptoms such as muscle tenderness or sinus congestion lead to eroneous diagnoses of tension-like headache or sinus headaches.

A recent study indicates that the most important clues can be summed up in the pneumonic POUND:
  • P = pounding or pulsatile (most important clue)
  • O = 4-72 hOurs
  • U = unilateral
  • N = nausea
  • D = disabling
When four out of the five are present, the accuracy is high. With fewer positives, the accuracy diminishes.

Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM. Does this patient with headache have a migraine or need neuroimaging? JAMA. Sep 13 2006;296(10):1274-1283.
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