Case histories

December 28, 2003

Ken, Atillo, and Other listmembers,

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. Ken Rose

I think this is a very good project, Ken, and I think that Atillo started

with a very good format .

I have looked into this issue of case history writing in TCM when I was

doing my Masters of Science in l995 (when I was enrolled in the subject

'Diseases and Society') and wrote a paper entitled " Remaking Traditional

Chinese medicine As contemporary Australian Medical Practice " One of the my

motives in writing the paper was the incrasing phenomenon of scientization

of TCM practice including the writing of it's clinical case histories which

is referred to in Chinese as 'Yi An' I am presenting below an expanded

version of the Yi An as written in my paper.

THE MEDICAL CASE RECORDS A TECHNOLOGY THROUGH WHICH EVALUATION PROCEEDS

" The medical case records is the basis upon which the TCM practitoner

makes his diagnosis and tratment of the patient. It is a record of

convergence between TCM theory and practice. It is a record of TCM practice.

It is a record of the process of " differentiating clinical patterns and

tailoring treatment. " (bian zheng lun zhi). It is also the concrete

manifestation of " choosing individual remedies for the formulae on the basis

of the established therapuetic method and principle (li fa fang yao). " ( A

General Introduction to the schematization and use of the Medical Case

Records " Journal of TCM , I have to get the complete name of the journal,

volume and date of issue. "

I GENERAL INFORMATION (The patient's name, sex, age, place of birth, place

of origin (ji guan); residential address; date of consultation. In case of

infants or minors, include the names and address of parents or guardian.

II Inquiry Wen Zhen

1. MAIN COMPLAINT : The main symptom or sign including location , nature ,

extent and time they appear. They must be summative using one or two words

to accurately describe them .

EXAQMPLE : " Recurrent colicky upper abdominal pain, accompanied by

vomitting for three times. "

2. HISTORY OR CURRENT CONDITION : This refers to the whole historical

developmental process of current condition. This can include: time of onset

of codition; what brought it about; where the symptoms occurred; nature and

severity of symptom; changes in symptomss; accompanying conditions;

treatment undergone and present state of illness.

3. CURRENT SYMPTOM This aspect requires detailed record including the " Ten

Questions "

a. CHILLS AND FEVERS : Averssion to cold; aversion to wind' fever, fever in

afternoon; high fever; slight fever; severe fever at night; fever at night

and feeling of coldness during the daytime.

b. SWEAT Spontaneous sweating; nightsweats; severe sweating; localized

sweating.

c. DIZZINESS severity; accompanying symptoms.

d. PAIN location; time; nature (descriptive)

e. CHEST chest congestion; chest pain; palpitations

f. ABDOMEN abdominal pain;(location , nature, alleviated by cold or heat;

alleviated by pressure or not); abdominal distention (extent); abdominal

lump (size, location, texture, tenderness).

g. APPETITE: Too much appetite and always hungry (xiao gu sheng ji); hungry

but no appetite to eat; no appetite to eat; inability to take in food;

absence of ability to taste food; acid taste in mouth; sweet taste in the

mouth; salty taste in the mouth.

h. FAECES AND URINE constipated. diarrhoeia, abnormal sensation when

defecating; Urine ( quantity, frequency, urgency in urinating; interrupted

urination ; uirination at night; incontinence .

i. S;EEP insomnia, sleepiness

j. MENSTRUATION, VAGINAL DISCHARGE, PREGNANCY AND MOTHERHOOD

1) age at initial period----duration of period---menopausal age

2)Menses colour; quantity (nummer of tampons used) texture

3) Vaginal Discharge (Dai) colour, quantity, texture and smell

4)Pregnancy: number of pregnancies, number of childbirths.

5)Child: normal period of gestation; premature; difficult labour;

history of infectious diseases; smallpox; measles, immunizatoion

Individual characteristics: prome to convulsions, diarrhoeia; asthma

History of previous illnesses: treatment and prognosis

III. Inspection (Wang Zhen)

A. WHOLE BODY INSPECTION

1. Spirit (Shen) normal, tired, dispirited, overactive, irritable

2. Consciousness: Clear, blurry, sleepu, uncounsious

3. Demeanor: natural and normal, suffering, frightened, worried, withdrawn ,

dull or happy

4/ Facial Colour: flushed, ruddy, red on both cheeks; bluish; purpple

5. Body Consittution: overweight ; thin

6. Decorum : moves naturally, oncomfortable with body movements; paralyzed;

half-body paralisis; shaking or tremors

B. REGIONAL INSPECTION

head; face, eyes, nose, ears, mouth, lips, throat, neck. chest and abdomen,

back and lower back, upper extremeties,

lower extremeties, skin, front yin (genitalia), back yin (anal opening)

C. INSPECTING SECREATIONS

saliva, vomit, faeces, urine, child index finger,

D. INSPECTING THE TONGUE

1. Colour : pink, red, purple, bluish

2. Appearance: Flabby, thin, fissures, teethmarks

3 Texture: stiff, soft, shaking, veers to one side; contrsacte4d , wagging

IV Listening and Smelling (Wen Zhen)

A. LISTENING TO THE SOUND

1. Voice: high pitch; low pitch; hoarse; voieless; screaming; moaning

2. Talk : talks a lot; talks little; delirium; talks to oneself; murmuring

in unconcious state

3. Breathing: wheeze; loud and hourse; slight and faint breathing; inhaling

more or exhaling less or vice-versa.

4. Cough: loud and big cough; hoarse cough; coughs like barking dog; chiken

sounding cough.

5. Vomit: high pitch and low pitch

6. Hiccps: high pitch and faint

B. FOUL SMELL

1. Mouth Qi acidic foul smell; fermented foul smell; very foul smell; foul

spirit smell; foul smell similar to decaying fruit

2. Sweat Qi Urine smell

3. Secreations : (including pus, phleg, vaginal discharge, urine and faeces)

4. Sick Person Room Qi : corpse smell; bloody smell, urine smell; smell of

decaying fruits; rotten smell

V Palpations (Qie Zhen)

A. Feeling the Pulse (mai zhen)

1. PULSE LOCATION

a. Superficial with soggy (ru) lethery (ge) hollow (kong) and scattered

(san)

B. Deep : with hidden(fu); frail (ruo) confined (lao)

C. Right Cun ---Guan--- Chi

d. Left Cun---Guan--- Chi

2. PULSE RATE Slow (chi), moderate(huan), rapid(shuo), galloping (ji)

3. PULSE SHAPE Threaddy(xi), minute (wei), long (chang), short (duan),

4. PULSE STRENGHT empty (xu); full (shi)

5. PULSE MOMENTUM (mai shi) flooding (hong), taut (xuan); slippery (hua)

moving (dong), choppy (se)

6. PULSE RHYTHM (Mai Lu) hurried (cu) knotted (jie) , intermittent (dai)

PALPATION Qie

1. Skkin:cool, hot, moist, dry. sweling, depressions

2. Hand and Foot: cold, hot, fever on palm. fever on back of hand , moist ,

dry

3. Chest

4. Abdomen: cool, hot, soft, hard, distended, lumps, tenderness

5. Acupuncture Points : knots, sensitivity, tenderness

VI . Differentiation Clinical Patterns BIAN ZHENG

A. Eight Principal Patterns

B. Patterns of Acupunncute Channesl

hand foot greater yang; hand foot lesser yang; hand foot bright yang; hand

foot greater yin; hand foot lesser yin; hand foot terminal yin

C. Patterns of Internal Organ Dishrnony

Heart--liver--spleen--lung-- kidneys

D. Patterns of Qi, Blood, Body Fluids Disharmonies

Deficient---Deficient----Deficient

Qi Blood Body Fuids

Excess Excess Excess

E Eiological Patterns

Exterior Afflications (Wai Gan) wind,cold,summer heat, dampness, dryness,

fore

Interior Trauma (Nei Shang() Seven Emotions , others

F. Patterns of Exterior Heat Afflictions

1. Patterns of Six Divisions

2. Patterns of Four Stages- Triple Burner

(The above is a translation of a segment of Deng Tie Tao's book Zhong Yi

Zhen Duan Xue TCM Diagnostics , People's Health Publishing House, (Beijing ,

l987)

December 28, 2003

December 28,2003