Guest guest Posted December 26, 2003 Report Share Posted December 26, 2003 All, I'm working on a project that includes development of a case history format. I'd be very grateful for any input that any of you might have to make as to criteria for designing such a format. My aim is to see a standard form in widespread use that will allow us to gather and summarize outcomes. And we need some sort of standard format for reporting data in order to do this. So, any thoughts on this topic are much appreciated. Ken Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 26, 2003 Report Share Posted December 26, 2003 Here is my case record version. Case Record 1. Surname: 2. First name: 3. Sex: 4. D.O.B: 5. Children: 6. Major complaint: 7. Symptoms: 8. Previous treatment: 9. History of the complaint (onset, progress, associated factor and triggers: 10. Brief medical history (childhood diseases, injuries, surgery, obstetrics, serious illnesses, allergies, vaccinations): 11. Current medication (name of drug, prescribed for, when prescribed, dosage): 12. Other complaints: 13. Energy levels (fluctuations, patterns, affected by): 14. Sleep (how many hours, quality, problems, dreams): 15. Appetite and diet (types of foods eaten, regular meals, erratic, preferences-hot/cold/spicy, alcohol, smoking, tea/coffee, drinks, weight changes, indigestion, nausea/vomiting, teeth/gums): 16. Bowel movements (regularity, quality, frequency, wind, constipation/diarrhoea, pain, blood): 17. Urination (frequency, urgency, quantity, smell, colour, difficulties, pain/stinging, incontinence, dribbling): 18. Menstrual history (LMP date, length of cycle, regularity, flow, quantity of blood, colour and consistency-clots/thick/thin, pain, PMS symptoms): 19. Obstetric history (pregnancies, births, miscarriages, complications, terminations): 20. Gynaecological history (discharge, thrush, infections): 21. Perspirations/temperature (preferences for heat or cold, flushes): 22. Brief details of hearing, vision, smell, taste in mouth, hair and skin quality, thirst, sexual energy: 23. Apparent mental state (confusion, mood changes, memory, balance): 24. Allergies: 25. Family history (diabetes, heart disease, high blood pressure, cancer): Attilio " kenrose2008 " <kenrose2008> wrote: > All, > > I'm working on a project that includes > development of a case history format. I'd > be very grateful for any input that any > of you might have to make as to criteria > for designing such a format. > > My aim is to see a standard form in widespread > use that will allow us to gather and > summarize outcomes. And we need some sort > of standard format for reporting data > in order to do this. > > So, any thoughts on this topic are > much appreciated. > > Ken Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 26, 2003 Report Share Posted December 26, 2003 Chinese Medicine , " Attilio DAlberto " <attiliodalberto> wrote: > Here is my case record version. > > Case Record > > 1. Surname: >>> Attilio: Where and how do you record the pulses? Jim Ramholz Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 26, 2003 Report Share Posted December 26, 2003 I have a line that says 'Head to Toe', near the bottom of the intake sheet, after the usual info and expanded ten questions, etc., so after gathering info, I can again toward the end of the interwiew, look the person over head to toe and bring any more sensory, logical or vague threads and diagnostics together. I guess to try to see for myself if I've been thorough and grasp who I'm dealing with. <attiliodalberto wrote: Here is my case record version.Case Record1. Surname: 2. First name: 3. Sex: 4. D.O.B: 5. Children: 6. Major complaint: 7. Symptoms: 8. Previous treatment: 9. History of the complaint (onset, progress, associated factor and triggers: 10. Brief medical history (childhood diseases, injuries, surgery, obstetrics, serious illnesses, allergies, vaccinations): 11. Current medication (name of drug, prescribed for, when prescribed, dosage):12. Other complaints:13. Energy levels (fluctuations, patterns, affected by):14. Sleep (how many hours, quality, problems, dreams):15. Appetite and diet (types of foods eaten, regular meals, erratic, preferences-hot/cold/spicy, alcohol, smoking, tea/coffee, drinks, weight changes, indigestion, nausea/vomiting, teeth/gums):16. Bowel movements (regularity, quality, frequency, wind, constipation/diarrhoea, pain, blood):17. Urination (frequency, urgency, quantity, smell, colour, difficulties, pain/stinging, incontinence, dribbling):18. Menstrual history (LMP date, length of cycle, regularity, flow, quantity of blood, colour and consistency-clots/thick/thin, pain, PMS symptoms):19. Obstetric history (pregnancies, births, miscarriages, complications, terminations):20. Gynaecological history (discharge, thrush, infections):21. Perspirations/temperature (preferences for heat or cold, flushes):22. Brief details of hearing, vision, smell, taste in mouth, hair and skin quality, thirst, sexual energy:23. Apparent mental state (confusion, mood changes, memory, balance):24. Allergies:25. Family history (diabetes, heart disease, high blood pressure, cancer): Attilio"kenrose2008" <kenrose2008> wrote:> All,> > I'm working on a project that includes> development of a case history format. I'd> be very grateful for any input that any> of you might have to make as to criteria> for designing such a format.> > My aim is to see a standard form in widespread> use that will allow us to gather and> summarize outcomes. And we need some sort> of standard format for reporting data> in order to do this.> > So, any thoughts on this topic are> much appreciated.> > KenMembership requires that you do not post any commerical, swear, religious, spam messages,flame another member or swear. To change your email settings, i.e. individually, daily digest or none, visit the groups?homepage: Chinese Medicine/ click 멷dit my membership' on the right hand side and adjust accordingly. To send an email to<Chinese Medicine- > from the email account you joined with. You will be removed automatically but will still recieve messages for a few days. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2003 Report Share Posted December 27, 2003 Jim, > > Where and how do you record the pulses? > How do you make your notes on pulses? Ken Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2003 Report Share Posted December 27, 2003 Chinese Medicine , " ken " wrote: > How do you make your notes on pulses? >>> Ken: In the Dong Han pulse system, we not only look at the pulses the way they do in basic Li Shi-zhen and Nan Jing styles but also in a variety of other ways; including more complicated models like those found in Suwen Chapter 20 and Mai Jing Book 10. Some essential features can be very small and take up only 1/27 of a single position, some patterns include multiple depths and positions; time calculations can't be drawn and are just scribbled on the side. So it needs to be done graphically. On my intake form there is a simple 9-sector diagram for each wrist; then I draw in the different patterns. Jim Ramholz Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2003 Report Share Posted December 27, 2003 Jim, I see. So, if I get this accurately, you use a template of a wrist on which you draw the shape of the pulses that you feel on examination, and you use this complex grid system as the focal points of change/no-change conditions in the linear movement of the pulse? I'm not sure that is well put, but I've read it over several times and can't figure out a different way to put it. Anyhow, thanks for your input on this. I'd been wondering myself how one might establish a standardized way of reporting pulses, where so many approaches and in the end personal variations are at play. Do many people use this same methodology of yours? And do you share data that is pegged to such descriptions? How does that work out for you? Ken Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2003 Report Share Posted December 27, 2003 Chinese Medicine , " ken " wrote: > I'd been wondering myself how one might > establish a standardized way of reporting > pulses, where so many approaches and in > the end personal variations are at play. > > Do many people use this same methodology > of yours? And do you share data that is > pegged to such descriptions? > > How does that work out for you? Ken: Because studying pulses is minimal in school and highly specialized in various lineages, I'm not sure how this can be solved. It would probably be best if standardization was limited to the Li Shi-zhen material since those ideas are the fundamentals, easily accesible in both Chinese and English, and something everyone needs to study before going on to anything more advanced. While we share some common ground with the Shen/Hammer system, for example, the Dong Han system has developed pulse diagnosis in different ways. While it has been originally a secret lineage in the past, I cover its ideas and methods in my articles and seminars. Jim Ramholz Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2003 Report Share Posted December 27, 2003 Jim, Got it. So how many people are currently using the system that you use, do you reckon? Would it be possible to aggragate case data pegged to pulse examinations from that cohort? Ken Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2003 Report Share Posted December 27, 2003 By and large, pulse diagnosis in a clinical setting is more a corollary than a parameter which originates a diagnostic concept. The Asking more or less, with the tongue, creates an image of the Design. Fine tuning Asking, more to pitch one aspect against an elemental profile, settles the issue. Pulse is then more a confirmation, a conciliation one is on the right track. In which case, no more than what is Full or Empty, and where, is what might be required. The Design will have already told you to expect Fast, Slow; or Deep or Superficial; even Full or Empty. The face color would have already told you to expect Wiry, the history to Hollow, the form to Damp, the skin and nostrils to Dry. The pulse then kicks in with an almost superfluous confirmation. Admittedly, the pulse can offer unpleasant surprises; but very rarely, and only when your Asking has been incomplete, hurried, careless, judgmental or pre-cognitive :-) I guess its OK to write in all variations of the Pulse in the case sheet; but sometimes More is Less, and Less, the other way around. Dr. Holmes Keikobad MB BS DPH Ret. DIP AC NCCAOM LIC AC CO & AZ www.acu-free.com - home based recertification for acupuncturists and health professionals Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2003 Report Share Posted December 27, 2003 Asking, more or less, decides the issue. In developing my Deep Diagnosis by Design, created a system by which parameters settled snugly into elemental qualities, creating, as Kaputcheck puts it, a Tapestry. Which is really final in its flow, and decided as to its destination. I found that if the questions were a possible 10 which needed to be asked, by 3 or 4, one had the Design. In which case one had the lurking Primary, and the noisy secondary. One Rx the former, and belatedly watched the latter settle down. Before a Design, a Pulse can but an Afterthought. Dr. Holmes Keikobad MB BS DPH Ret. DIP AC NCCAOM LIC AC CO & AZ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2003 Report Share Posted December 27, 2003 Chinese Medicine , " ken " wrote: So how many people are currently using > the system that you use, do you reckon? > > Would it be possible to aggragate case > data pegged to pulse examinations from > that cohort? Ken: There were 3 of us in 1990 who had originally learned the system. Now that I've been teaching for the past few years, there are more practitioners around the country who have varied degrees of time in and ability; about 224 to my forum, although not all of those have taken my seminars. From their feedback, it would be possible to aggragate some data from the ones in the group who have had more exposure to the material. As I go around the country teaching, I always ask practitioners what pulse training their schools offered. The answers vary from one day to one semester of study before going into the school clinic; but the material covered was essentially from the Li Shi-zhen. Jim Ramholz Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2003 Report Share Posted December 27, 2003 Chinese Medicine , " dr. k " wrote: > By and large, pulse diagnosis in a clinical setting is more a corollary than a parameter which originates a diagnostic concept. >> Holmes: This is the case for most practitioners. But it's really a matter of what has been available to you and emphasized in your training. For me it's the other way around. For instance, my teacher never talked to the patient outside of learning their major complaint and age. He could extract their entire medical and emotional histories using the pulse. I talk to patients more--- not always having an hour or so to spend on reading their pulses--- and always rely on the pulses for their diagnostic information. Jim Ramholz Quote Link to comment Share on other sites More sharing options...
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