Chief Complaint: Left Heel Pain
Medical History: At age 14, he was diagnosed with polio. And ever since then fear has been one of the predominating emotions in his life. In 1997, he voluntarily underwent a vasectomy. He felt this would allow him to engage in a fulfilling sexual lifestyle, without the worry of ever having any children.
He is a tall man, standing over 6’5, and possessing a very muscular physique. He is also currently undergoing marital strife, as I also treat his wife as well. There are seeking marriage counseling.
Chief Complaint: The thyroid was enlarged.
Western Diagnosis: goiter due to iodine deficiency
Medical History: The patient’s thyroid got enlarged, hard, accompanied with headache, stuffy nose, tending to catch cold and get tired, irregular menstruation, lumbago, neck soreness, and irritability.
Pulse exam: Pulse is wiry and thin.
Tongue exam: Tongue is red with white coating.
OM Diagnosis: Liver qi stagnation
Chief Complaint: Epigastric pain
Medical History: Male, 29
At age 16 the patient realized he couldn’t eat fried, greasy or rich foods on the same day as playing soccer without experiencing a burning sensation from the stomach to the throat. Began taking pepsid with a little improvement. At age 21, while in Sri Lanka he ate some yogurt which made burning so bad that the pepsid did not work. Accompanying symptoms included slight fever, irritability, and profuse diarrhea with a fetid odor and a burning sensation. Upon return to the U.S. he was diagnosed with Giardia and Amoebas. Prescribed Flagal which stopped diarrhea. Prescribed Prilosec for reflux which helped. At age 22, he stopped Prilosec and began managing the reflux with Chinese herbs.
Chief Complaint: lower back pain for 6 years
Western Diagnosis: L3-L5 Hyperosteogeny
Medical History: Patient has been suffering from lower back pain for 6 years, and the pain, accompanied with sciatica for 3 months, gets worse when he is tired. He had chiropractic treatment for 3 months, but it was not efficiently improved.
Pulse exam: Pulse is wiry and fast.
Tongue exam: Tongue is purplish and redish with little coating.
Chief Complaint: menstrual pain
Western Diagnosis: dysmenorrhoea
Medical History: This 35 year old lady has been complaining of pain and cramping after onset of period for past six months,and passing large clots with menstrual flow.She also reports extreme moodiness premenstrually.
Pain and cramping is relieved by pressure.She tends to feel hot but gets cold after eating.Her digestion is normal and bowels regular.Urination is normal with no nocturia. Sleeps well but wakes up feeling fatigued.
She has a history of Yang Ming headaches due to sinus congestion and was treated for post nasal drip due to allergies.
Chief Complaint: yeast infections
Western Diagnosis: yeast infection/candida
Medical History: Patient complains of consistent vaginal yeast infections. She excercises regularly, eats a lot of sugar in her diet and is on the birth control pill. She is a first year lawyer and is under a great deal of pressure.
Chief Complaint: lower back discomfort, hot feet.
Medical History: Female approx 50 + y.o.
Presenting Challenge: Discomfort in lower back last 12 months or so, can vary from sore or can’t get comfortable, to a sense of tired, weak. Also digestive challenges leading to diminished appetite pattern of irregular food intake due to varying work schedule.
Irregular menses last 2 years, last period 6mths or so ago.
Otherwise feels general health to be pretty good tho work schedules can be a bit taxing when busy.
Chief Complaint: Stress with accompanied symptoms is his chief complaint.
Medical History: Patient was seen for the first time in February of 2001. This was his first experience with acupuncture.He appeared anxious.His work is in selling bonds and he is not really happy with the job situation. Stress and the following symptoms were discussed:here was a past history of indigestion and chest pains. He exercises frequently and tries to watch his diet. His father died at 72 of heart disease . He used alcohol regularly and drinks 2 cups of coffee daily. Sleep can be irregular and takes Valerian and sometimes sleeping pills.
Chief Complaint: Headaches
Western Diagnosis: Migraine
HPI: a 44 years old F. pt. seeks acupuncture treatment for her migraine today. her condition started when she was in 4th grade and has been treated by many doctors and modalities without satisfactory improvement. The patient denied her migraine associated with menstrual cycle or optical status but stress. Additionally, the pt. mentioned she would have a headache again if she skips meals a day. The pain primarily takes place on the left temp. area in a tense/consistent fashion, and could last form a few hours to 3 days, which affect concentration and feel exhaustion. She complaint ache and tension on the neck and shoulder areas, too.
Chief Complaint: insomnia
Western Diagnosis: insomnia.
Medical History: Insomnia for the last 18 months which started when the patient changed his job. He worked for 20 years doing shift work in the airforce, yet when he changed to a regular day job 18 months ago he started to suffer from insomnia. He used to get a maximum of 2 1/2 hours sleep each night. Sometimes he fell asleep easily and then woke up later on, and then was unable to get back to sleep. Other times it took him 2-3 hours to fall asleep and then he would wake up again and was unable to return to sleep.
He relaxed and walked the dog before going to bed. Very rarely had dreams. Very little alcohol, doesn’t smoke. Good diet; chicken, fruit, veg, little dairy. Last meal of the day was at 4.30pm. No coffee, 2 cups of tea daily.
He appeared very calm at the consultation. None of the usual patterns of disharmony within TCM stood out, such as; Heart Fire, Liver Fire, Blood deficiency, Liver Yin deficiency, etc.