Chief Complaint: back and neck pain
Western Diagnosis: myofascial pain syndrome, “herniated and bulging discs”
Medical History: The patient came for treatment in 2001.
The patient is female, 25yrs old.
5′ 6″ 160lbs
2 children ages 3 and 6
Employed in Customer service fora Medical Clinic
Severe pain began following MVA in 1987. Subsequent MVAs in 97, 98, 99, 00, and 01. Surgery on RS knee 3X.
Chief Complaint: Allergies
Western Diagnosis: Rhinitis, Allergies
Medical History: 10 years history of runny nose, Sneezing, itchy eyes, watery eyes, tiredness.
Questioning exam: Lung Qi deficiency and excess dampness on sinus area
Pulse exam: Wiry and slippery pulse.
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: Migraine Headaches
Western Diagnosis: cervical spondylosis, C4-5 disc protrusion
Medical History: Dishwasher fell on his head July 2003. He was taken to ER, x-rays taken, neck brace put on and sent back to work. He received PT and chiropractic treatments. Minimal improvements. He is a martial arts expert, and in very good physical condition. His diet varies from healthy foods to junk. He has a hx. of allergies, and diverticulitis as a child. He has Raynaud’s disease, and TMJ dysfunction. He smokes cigarettes.
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 .