Chief Complaint: Facial Pain
Western Diagnosis: Trigeminal Neuralgia
Medical History: Patient is a 50 years old male, well nourished. Physical examination revealed 135/95 blood pressure, otherwise appears to be in good health.
Blood Analysis: within normal range
MRI of the brain: Findings: the internal carotid and basilar arteries, proximal anterior and middle cerebral arteries are normal in caliber, contour and signal intensity. No congenital aneurysm or mass effect.
Impression: Normal examination.
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: Pain and numbness post-surgery.
Western Diagnosis: Benign brain tumor located superior to l. mastoid process.
Medical History: Patient is a 35-year old female with main complaints of: reovering from l. mastoid/benign brain tumor, right lower quadrant abdominal and l. eye surgery (wt. put in l. eye m. so upper/lower lids would be functional). Secondary complaints include emotional trauma related to family situation/ pending divorce.
Questioning exam: Questions mainly revolved around post-surgical sx/s. Including: loss of sleep, numbness l. side of face and behind l. mastoid process/ear at incision site. Left side of face muscles do not function: patient can smile and use mouth on the right side but not left side.
Chief Complaint: Severe tremors/restricted movement
Western Diagnosis: Parkinson’s Disease
Medical History: A 52-year-old male has been suffering from Parkinson’s disease for 5 years. He has experienced severe tremors in all extremities, difficulties in speech, loss of coordination, lapse of memory, etc. Despite western medications and continuous medial treatments, his conditions got worse to a point that his doctors suggest a brain surgery.
Questioning exam: Severe tremor attacks in a 15-min interval. His gait is non-focused and the patient occasionally lose speech functions. Extremely pale and low energy level. Hot in the upper torso, and cold hands and feet.
Chief Complaint: Fatigue, nausea and loss of appetite.
Western Diagnosis: HIV Positive
Medical History: Male, 33 years of age, 5’10″, 175 lbs., full time student/part time bartender. Diagnosed HIV positive in 1989 remaining healthy with no complications. Currently (2002) and since 1996 patient on triple drug therapy of Indinovir, 3TC and AZT due to high viral load. Current viral load measures 200,000 copies per milliliter. Most notable side effects are chief complaint of fatigue, nausea and loss of appetite. Irregularly exercises, meditates and practices Qi Gong daily. Eight hours of sleep consistently but restless with dreams most nights, Excellent organic non vegetarian diet, mealtimes at regular hours 3x daily. Exposure to smoke daily.
Chief Complaint: calf pain and swelling
Western Diagnosis: phlebitis
1.Recurrent phlebitis on left calf-had same exact symptom seven years ago. He took Chinese herbal medicine and the symptoms were completely gone. It took 6 weeks to cure it.
3. lost his right leg on auto accident
4. doesn’t drink alcohol but drinks a lot of water
5. He delivers auto parts-driving 8 hours per day. He used to work at a post office where he had to stand for 8 hours per day, again
6. His blood pressure and pulse rate is normal.
Chief Complaint: Over Weight and High blood pressure
Western Diagnosis: Obesity, high blood pressure
Medical History: 45-year-female who has been overweight for nearly 30 years and has high blood pressure for nearly 12 years.
Questioning exam: Do you have a normal appetite?
No. Sometimes I can’t control myself even under the condition I don’t feel hungry I must eat.
Pulse exam: Heart and liver pulse are superficial.
Chief Complaint: sporadic menstrual cycles
Western Diagnosis: amenorrhea
Medical History: 27 year old female triathlete. Runs, bikes, skis. Menstrual cycles sporadic since age 16. Diet fairly balanced, except red meat and iron rich foods lower than needed. Until recently patient worked three jobs.
Questioning exam: 1-2 menstrual cycles a year presenting with low back cramping, onset with brown blood, duration 3-4 days, ending with brown blood. Flow remains light throughout cycle. Fatigue during cycle. especially. Low grade anxiety, cold hands and feet, slight constipation, occasional floaters, and sometimes hard to fall asleep, especially prior to onset of cycle. Patient also complains of “coming down with every cold that comes along”.
Chief Complaint: chronic diarrhea
Western Diagnosis: IBS
Medical History: 34 year old Caucasian female, bookkeeper. Presents with scoliosis, lower and upper back pain, irregular menses. Patient does not exercise and eats lots of fried foods.
Questioning exam: Patient sighs frequently, has breast tenderness, distention, bloating and gas. Chronic dawn diarrhea with undigested food and mucous. Symptoms increase with menses. Patient has a heavy flow with many, large clots and dark blood. She sees floaters and frequently feels hot. She has seasonal allergies.
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.