Chief Complaint: Recurring Nightmares
History: Patient was an 23yr old female who had no previous major medical history. She had a tonsillectomy when she was in grade school (did not remember age) . No medications, no history of abuse and could not think of any specific physical or emotional trauma.
Symptoms: Recurring dream of being chased then strangled. Initial onset was about 1.5 months prior to tx with an occurrence about 2/3 times per week. Patient was having difficulty sleeping due to anxiety about having nightmare and would sleep very lightly. After dream would usually stay up about 2 hours to calm herself down. All other functions seemed normal.
Chief Complaint: Abdominal Pain
Western Diagnosis: Acute Gastritis
Medical History: Patient is a 30 year old female student. Average diet. In general runs cold and damp with underlying KID yang def.
Questioning exam: Patient had pain in lower abdomen and left lower quadrant following a night of drinking ETOH (Ethyl Alcohol i.e. beer and alcohol) and greasy foods. Felt burning dull achy pain in LLQ. Loose stools with burning at evacuation.
Chief Complaint: Seasonal Allergies/pain in lower back and hips (SI joints)
Western Diagnosis: Seasonal allergies and Ankylosing Spondilitis
Medical History: Patient is a healthy appearing 28 year old male who has a history of allergies (ragweed, dust) since childhood and more recently diagnosed with Ankylosing Spondilitis 3 years ago after a pain in his toes (middle toe on rt, second on lt). No treatments have affected the seasonal allergies. Patient is currently taking Hydroxychloroquine for the Ankylosing Spondilitis as needed by his rheumatologist. Stiffness in the morning but gets better as day goes along. Nothing remarkable in the diet. Patient is physically active as a father (4 year old) and soon to be again.
Chief Complaint: Leg numbness, sciatica
Western Diagnosis: Narrowing, of L-4,L-5 diskspace
Medical History: 59 year old male,sedentary, overweight. Gradual onset of low back pain leading to sciatica now with numbness of in L-4, L-5 dermatone. Numbness began 2 years ago.
Questioning exam: Low back pain is dull, numbness increases with movement and cold and/or damp weather. Frequent urination as well as dribbling of urine.
Chief Complaint: Prickling pain the lower legs and feet and low back pain
Western Diagnosis: Ideopathic peripheral neuropathy, osteoarthritis, osteopenia
Medical History: Patient is a 64 year old female who suffered an anxiety attack five years ago and a TIA three years ago before being diagnosed hyperthyroid and underwent a radioactive iodine treatment. She is now hypothyroid taking supplemental levothyroid and a daily 80mg aspirin. Patient suffers from osteoarthritis in the knees, feet and hands with visible deformity. Patient also suffers from osteopenia and takes Fossamax weekly. Otherwise, patient has an excellent diet and walks regularly. Patient lives near her family and sees them regularly, she also participates in various classes for seniors at the local community center.
Chief Complaint: Migraine and edema in legs
Medical History: Has taken contraceptive for 1 year.
Questioning exam: Migraine with nausea and mouth ulcers for over 10 years. Temporal and on the right side with loss of vision in the left eye and numbness in the left arm.
Dizziness on standing up
abdominal and lumbar pain during period.
Chief Complaint: neck and shoulder pain/tension
Medical History: patient woke up with crick in neck one week ago, initially got better, then today much worse.
Questioning exam: pain at base of skull (UB10/GB 20 area) and shoulders (GB21 area) more L sided; irritability; pain at 7 on scale of 1-10.
Pulse exam: pulse wiry overall
Tongue exam: red sides and tip, scant coat
Chief Complaint: sporadic diarrhea followed by severe Rt. quadrant pain and high fever
Western Diagnosis: Crohn’s disease
Medical History: Diagnosed as Crohn’s Disease ten years ago. The frequency of the episode progressively changed to few times a year to twice a month. History of double hernia surgery 15 years ago.
Questioning exam: Malar flush, mild afternoon fever.
Chief Complaint: Rashes, heart burn and sudden onset fatigue
Western Diagnosis: Hives and Acid reflex associated with stress
Medical History: Patient is a 40 year old female, who generally is in good health. She has had hives since childhood, hives comes and goes. Anti-histamine medication or prednisone did not help in the past. She used to take patent herbs for a few days, the rashes would be gone for a couple of months. Wherever she did not get enough sleep or stressed out, the rashes showed up again. Also each time she got pregnant, she tends to get hives. She never had heart burn before, but sometimes has bloating and indigestion when she eats greasy food .
Chief Complaint: constipation, cramps
Western Diagnosis: irritable bowel syndrome
Medical History: 21 y.o. woman in apparently good health except for IBS symptoms, acne, insomnia, terrifying nightmares, depression, anxiety and fear, history of post traumatic stress due to near lethal assault 5 years before. Unhappy family and relationship History:history of abandonment and neglect. Stuck in dead end job, strong creativity frustrated.