Chief Complaint: Allergy and Insomnia
Western Diagnosis: Allergy and Insomnia
Medical History: Dizziness, fatigue, frontal headache, insomnia, asthma, nausea, earache, hay fever, sinus problems. back, legs, neck and shoulders pain, Lumps in groins.
Allergic to passion fruit, chamomile, some fruits, cats, horses, goats, deers, some herbs.
Questioning exam: Allergy and asthma since pt was born and has been tested and confirmed by specialist. Symptoms included daily sneezing, itchy throat, running nose, stuffy ears, frontal headache, and frequent skin rush.
Chief Complaint: Muscular pain/ achiness
Western Diagnosis: Fibromyalgia
Medical History: Patient: female, 42 years old
Since February 2000, patient had experienced muscular pain. In April 2000 she was diagnosed with Lyme’s dx and put on antibiotics. After no relief, a spinal tap and Tender Point Assessment test were performed. She was diagnosed with fibromyalgia in the summer of 2000. Significant medical history includes saline breast implants in 1983, gall bladder was removed in 1984 and in 1993 the patient was diagnosed with severe allergies and asthma. Medication at the time of visit included Arthrotec and Maxalt.
Chief Complaint: fibromyalgia and chronic fatigue
Western Diagnosis: fibromyalgia Jan 2001
Medical History: A 50 year old female, health care professional and PhD candidate, sought Chinese medicine for the first time on May 11, 2001, with symptoms of fibromyalgia for one and a half years prior to formal diagnosis in January 2001.
Patient’s physical activity had been limited, since exercise aggravated her symptoms. Symptoms were also aggravated by stress and inactivity. A physician prescribed Prozac, 10 mg on odd days, 20 mg on even days, Premarin 1.25 mg daily, and glucosamine chondroitin, dosage unspecified. The patient also took a daily multivitamin and calcium supplement. There was mild improvement in her condition on this regimen, but she was advised that she would “just have to live with pain.”
Chief Complaint: Numbness and tingling in lower extremities
Western Diagnosis: Peripheral Neuropathy diagnosed in 1996
Medical History: Illnesses and Operations:
Chief Complaint: Chest congestion with cough that started in the fall 3 years ago
Western Diagnosis: chronic bronchitis
Medical History: Medical History:
a. History of Present Illness: The patient has been suffering from chest congestion with cough for over three years. The condition usually worsens in the months of October and November. It becomes aggravated with heat. 14 days ago it worsened and became a cold. The days before she got the cold, she went and took saunas and steam baths regularly for therapeutic reasons. She was hoping it would help her chest congestion. Two weekends ago it manifested as a cold. She has a dry, hacking cough. The cough contains phlegm which is difficult to expectorate and the color of it is yellow. In addition she has yellow sticky nasal discharge. She feels depressed that she is not feeling well.
Chief Complaint: allergies
Medical History: Patient is a 30 year old male, sedentary lifestyle,diet includes much dairy and spicy foods, no excessive smoking or drinking.
Questioning exam: Patient reported being under stress and feeling very congested with yellow phlegm, a lot of sneezing, itchy watery eyes, fatigue, and a sensation of heaviness in his head. Condition was worsened by the drafty environment he worked in.
Pulse exam: Pulse was slippery and somewhat weak
Chief Complaint: frequent sinus headaches, sinus drainage
Western Diagnosis: allergies
Medical History: Marked fatigue, bronchitis, sinus drainage. Her headache is behind the eyes. She also sometimes has one-sided headaches.Digestion-sometimes soft stool, occ hard, dry stool. Marked acid regurgitation, and some abdominal bloating. Patient is markedly overweight and admits that she likes sweets. Her periods are painful, with cramps. She occasionally has one-sided headaches; also has significant neck and shoulder pain. The patient takes Zyrtec and Flonase for her allergies. The Zyrtec makes her tired.
Chief Complaint: Hives with itchiness
Western Diagnosis: Allergy
Medical History: 37 female, full-time mother of two children.
Developed the Hive condition all over the body in Oct 2004.
Approx 30 lbs overweight. Went to a dermatologist to check for allergies but found none. Indicated that she can only wear gold/silver jewelries. She likes to eat Cheese but does not drink Milk, nor smokes. Has a mild scoliosis. Taking over-the-counter allergy pills but needed to take more recently (every 12 hours or more). She feels stressed taking care of kids and not getting enough sleep. She also reported a nagging lower back ache.
She never had a acupuncture before.
Chief Complaint: Uterine pain
Western Diagnosis: Fibroids
Medical History: Asian female,age 40 presents with uterine fibroids for 14 years. Asthma since age 6, medicated with steroids for many years; during acute attacks her brother (physician) would intravenously inject her with a steroid cocktail; at age 25 she began daily use of ventolin spray; allergies to pollen, cats and coconut; whole family history of skin or lung problems (eczema, vitiligo, lung infections)
Chief Complaint: Headache 40 +years, adverse 12 years
Western Diagnosis: Daily tension headache, migraine
Medical History: A 57 year-old Female, got headache when she was 12 years old.At the beginning, the headache just occurred each week, and the time was not lasted very long–3-4 hours per time and the pain was not located a specific part.After took pain-killer drug,it could be relieved.12 years ago, the headache became more and more frequent, almost headache every day, and from the morning to evening, the patient had to take medicine everyday,about 3-4 pills a day.