New case Patient Number: 0702047028

[Guest guest]

Hi Everybody!

 

New case, most unusual to have a patient in the summer time! As always, I

welcome your comments.

 

Patient: female Record 7-2-4

 

Patient Number: 0702047028 age 65

 

What is your major complaint? Digestion problem, swelling, burning

hypogastrium, sometimes lower (GI) as well.

How long have you had this condition? 7 years

What treatments or remedies have you tried for this condition? Zantac,

lemonade, alkaline diet.

 

Have you ever had stomach, liver or intestinal trouble? Yes.

Have you ever had gallbladder trouble or gallstones? No, but Dr. in Mexico

said she had no bile, gave her artificial bile pills.

Have you ever had a reaction to serum, drug or medicine? Yes, penicillin.

Have you ever had to wear eyeglasses? Yes.

Have you ever had eye trouble? Yes, lasic surgery for glaucoma.

Have you ever had ear, nose or throat trouble? Yes, at age 3 she suddenly

could not hear on the right, eventually recovered 80%.

 

(female only section)

Have you ever had a pregnancy? Yes, miscarried.

Have you ever had painful menstruation? Yes, when a teenager, used to take

Lydia Pinkham remedy for it.

How old were you when you had your first menstrual period? 11.

What was the interval between your menstrual periods? 28 days mostly.

How long did your menstrual periods last? 3 to 5 days.

When was your last period? At age 48.

Have you ever had or do you now have loss of sexual desire? Decreased after

menopause, is better when she practices her Yoga and exercises.

(end of female only section)

 

Have you ever had or do you now have shortness of breath? Frequent, stomach

pain takes her breath away.

Have you ever had or do you now have hoarseness? Seldom, last time was 3

years ago because of air conditioning.

Have you ever had or do you now have sore throats? Frequent, last 3 months.

Have you ever had or do you now have diarrhea? Seldom, last time was 3

years ago.

Have you ever had or do you now have decreased appetite? Frequent. Often

feels too sick to eat.

Have you ever had or do you now have arthritis? Seldom, affects her fingers.

Have you ever had or do you now have weakness? Seldom, had West Nile Virus.

Have you ever had or do you now have fever? Seldom.

Have you ever had or do you now have insomnia? Seldom.

Have you ever had or do you now have nervousness? Seldom.Have you ever had

or do you now have irritability? Seldom.

Have you ever had or do you now have morning tiredness? Seldom.

Have you ever had or do you now have easy fatigability? Seldom. Because of

the West Nile, she can be lazy and now has to take vitamins, yoga and

Ceregar table treatments every day. This is a table similar to a Spinalator

that has jade rollers. Has used this for 5 months.

 

Have you ever been refused employment because of your health? Yes.

Why were you refused employment because of your health? Formerly taught

yoga, has to give that up due to her health.

Do you have or have you had weight gain recently? Yes, 4 lbs.

Do you have or have you had a change in your handwriting recently? Yes,

worse in the last 15 years.

Do you have or have you had balance problems recently? Yes, better since

Lasic surgery.

Do you have or have you had ringing ears recently? Yes, only on the right,

is improving.

Do you have or have you had a change in the color of your skin recently?

Yes, was sallow.

Do you have or have you had a tendency to bruise easily recently? Yes.

Do you have or have you had athlete's foot recently? Yes, use soaps and

powders but still, I recommended tolnaftate product.

Do you have or have you had cold intolerance recently? Yes.

Do you have or have you had a change in your shoe or hat size recently?

Yes, feet are one size larger now.

Do you have other items of physical fitness you want to mention? Yes, spine

is not good, especially cervical spine. Recommended Dr. Horrigan to her for

this.

 

Is there a history of diabetes in your family? Yes, her brother, 15 years ago.

Is there a history of cancer in your family? Yes, aunt and mother. Dr. in

Mexico cured her with simple medicine.

Is there a history of high blood pressure in your family? Yes, mother (in

early 80s) she is a hypochondriac.

Is there a history of glaucoma in your family? Yes, she may have had

glaucoma herself, was treated by lasic surgery.

What medications do you currently take? Zantac, sometimes for main meals or

before a party.

 

Please list all operations you may have had, and your age when you had them.

Lasic, six months ago.

Appendectomy in her late 20s.

Plastic surgery on her face, 3 years ago.

 

Observe Examination:

 

Dry lifeless color indicates exhausted Stomach-Qi)

Red color (may indicate Inflammation, fever or infection) A little red at

yintang point.

Small pointed head, fast moving & small hands " Fire Type " . Yes.

Fat body. Yes.

Clear thin phlegm, cold pattern.5 element ear problem is mainly kidney;

tinnitus is yin deficient, hyperactive fire liver or kidney.

Loose teeth, kidney essence deficient. Dr. Hall, her dentist, " forced " her

to have her wisdom teeth removed. She consented to this but it was against

her better judgement. She still sees him for cleaning every 4 months.

Tongue color. Pink.

Tongue shape. Teeth marks.

Tongue coating. White.

Tongue moisture. Moist

 

Inquire Examination:

 

Aversion to cold. Yes. (exterior cold/wind)

Sudden onset of headache. Very seldom.

Gradual onset of headache. More usual.

Location of the headache. Occiput, moves to vertex.

Character of the headache pain: Bursting.

Condition of the patient while having the headache. Puts her in a bad mood.

Pain that is worse after eating. Yes. (excess)

Pain with bloating or a sense of fullness. Yes. (excess)

Sensation of heaviness. Yes. (damp cold, damp heat, qi deficiency or bi

syndrome)

Pain that moves from place to place. Yes. (wind)

Clear Urine. Yes.

Undigested food in the stool. Yes.

Thirst, appetite and tastes.

Not able to fall asleep. Yes.

Dream disturbed sleep. Yes. Better in the last 6 months.

Pain before periods. Yes.

Pain during periods. Yes.

Taking contraceptive pills. Only took them once, stopped because of a reaction.

Change in the skin, such as flaccid skin. Yes. When she stops yoga.

Change in the bones, such as brittle bones. Perhaps, she broke her wrist 12

years ago.

 

Listen & smell Examination:

 

Has slight acid odor.

 

Palpate Examination:

 

Systolic blood pressure (Optimal <120; Normal <130, Today it is 124.

Diastolic blood pressure (Optimal <80, today it is 77.

Heart rate. Today it is 70.

Floating pulse. Yes. (weak, deficient yin; strong, interior wind)

Short pulse, does not fill the spaces under the three fingers and is

usually felt in only one position. Yes. (often sign of deficient qi)

Radial pulse: Left proximal (third) Kidney Yin cannot be felt.

Dry skin. Yes. (deficiency of liver blood)

 

Acupuncture diagnostic impressions: (summarized from examinations)

 

Observe Examination:

 

Exhausted Stomach-Qi.

A little red at yintang point. (may indicate Inflammation, fever or infection)

" Fire Type " .

Fat body. Yes.

Cold pattern.

Kidney; tinnitus is yin deficient, hyperactive fire liver or kidney.

Kidney essence deficient.

Tongue shape. Teeth marks.

Tongue moisture. Moist

 

Inquire Examination:

 

Aversion to cold. Yes. (exterior cold/wind)

Gradual onset of headache. More usual.

Location of the headache. Occiput, moves to vertex.

Character of the headache pain: Bursting.

Condition of the patient while having the headache. Puts her in a bad mood.

Pain that is worse after eating. Yes. (excess)

Pain with bloating or a sense of fullness. Yes. (excess)

Sensation of heaviness. Yes. (damp cold, damp heat, qi deficiency or bi

syndrome)

Pain that moves from place to place. Yes. (wind)

Clear Urine. Yes.

Undigested food in the stool. Yes.

Thirst, appetite and tastes. ?

Not able to fall asleep. Yes.

Dream disturbed sleep. Yes. Better in the last 6 months.

Change in the skin, such as flaccid skin. Yes. When she stops yoga.

Change in the bones, such as brittle bones. Perhaps, she broke her wrist 12

years ago.

 

Listen & smell Examination:

 

Has slight acid odor.

 

Palpate Examination:

 

Floating pulse. Yes. (weak, deficient yin; strong, interior wind)

Short pulse, does not fill the spaces under the three fingers and is

usually felt in only one position. Yes. (often sign of deficient qi)

Radial pulse: Left proximal (third) Kidney Yin cannot be felt.

Dry skin. Yes. (deficiency of liver blood)

 

Follow-up: 7-9-4 When I saw her the third time I commented to her that her

case was complex, signs of both excess and deficiency. She said she

expected that because the Ceregar table instructions say that while the

Ceregar table treatments are healing the body, the diagnostic signs will be

confused! I brought down several medicines from my shelf and looked them up

in the new Fratkin book. While I was doing this she decided she wanted to

take Lanzhou brand Shu Gan Wan because she liked the color scheme of the

box. Well, it was the one I was considering as the most likely starting

point of what I had available to me, but how coincidental is it that she

liked the box? I will see her again on Friday. In addition to taking the

pills she will be keeping a food journal to try to associate her feelings

with what she eats.

 

Regards,

 

Pete

[Guest guest]

Do you have a copy of your intake form you can email me. I also emailed you the

2 articles from JAMA.

Brian

 

Pete Theisen <petet wrote:

Hi Everybody!

 

New case, most unusual to have a patient in the summer time! As always, I

welcome your comments.

 

Patient: female Record 7-2-4

 

Patient Number: 0702047028 age 65