Chief Complaint: headache, finger & feet numbness, asthma
Western Diagnosis: degenerated inflammatory polyneuropathy
Medical History: hepatitis, allergy, asthma, high blood pressure,liver removal surgery, in-born one kidney, vegetable diet with dairy products, little exercise, obesity
Questioning exam: -How long you have these symptoms?
-Asthma since a little child. Hepatitis since surgery. Headache for about 10 years.
Chief Complaint: Joints pain for over three years
Western Diagnosis: Mixed connective tissue disease, pulmonary hypertension, scleroderma.
Medical History: A 23-year-old woman was admitted to clinic on May 5, 1997, because of joints pain around all body for over three years, skin and eyes dry, thirst and wants to drink cooled water, almost joints sour and tip of fingers’ color change to purple and whit when the weather become to cold, loss hair. Her skin on arms are dry and peeled off. She used to treat by acupuncture and Chinese herbal medicine, the symptoms were reduced but that never goes away. Recent years, she has had sense of oppress in her chest, and difficult to breath, asthma attack when she walk or go up stairs, those symptoms are gradually getting worse, but nothing could help. During 12/03-12/18/1996, she had had a high fever and went to Johns Hopkins Hospital was diagnosed as mixed connective tissue disease, pulmonary hypertension, scleroderma.
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: 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: 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: Chest tightness and palpitations chronic for eight years with an acute presentation for 2 weeks.
Medical History: The patient has been tested by a medical doctor for heart problems. The tests including an EKG, Stress Test, and blood values of cardiac enzymes show that the patient is within normal range. Her symptoms generally include tightness in the chest that is always present and palpitations while resting that can last as long as 20 minutes. On several occasions she experienced pain radiating down her left arm. The problem began 8 years ago after her fiance died. Prior to this incident she did not experience any of the signs and symptoms described above.
Chief Complaint: anger management
Western Diagnosis: ADHD with Oppositional Disorder Defiant Disorder
Medical History: Patient is 13-year-old male student, 108 lbs., 5’6″, whose only other medical history was a case of asthma two years prior and pneumonia four years prior to first visit. Patient is only son/child of and resides with his parents and has two older step-sisters from mother’s previous marriage (one of whom is still at home). Family had relocated from urban to rural area approximately 4 years prior and patient held resentment and had grieving issues over leaving his home and friends behind.
Chief Complaint: wheezing, phlegm
Western Diagnosis: childhood asthma
Medical History: Child is 7 yr. old boy who has had this problem since diagnosis at 6 mos. old. Allergies to nuts, cats, feathers, and is sensitive to diary (uses soy/rice milk, but will eat cheese and eggs). He is an active child, enjoys socializing with his friends, and is very much a “boy”. He won’t come “out of the rain” unless he is told to, even though he knows the consequences will be sickness. When he gets sick, he’s down and needs to have extra medicines, such as, Pediapred. Mother uses a combination of natural and prescribed medications; the homeopathics for strengthening and for minor symptoms, the western for keeping him out of the hospital and because the schools and daycares will not administer herbs. When severe, has chest tightness.