Course: Clinic Theater 2

Class #: 5

Date:

8/15/08

Initials/age/gender

Alison B new patient

Chief Complaint
Current Assessment
and Related Histories

Poor memory/poor concentration, low energy, headaches, concussion for 6 months.

Concussion Jan 08 fell off bike
Also had concussion 1 yr before.
Major memory issues (short term), trouble concentrating thru class. Cant study longer than 15
minutes at a time.
SOB in morning
Headaches: Stress headache. Had headache x1week occipital to vertex.
Also ache at top of maxillary sinuses but this seems to be allergies.
Energy: generally fatigued, sleep a lot. Reduced physical activities. 6/10 right now.
Sleep: sleeps a lot, lots of dreams, would probably sleep thru the night if she didnt have cats. 10
hours sleep a night + 2-3 hour nap. Used to get 6 hours and be fine + workout.
Dizziness/vertigo: Yes, easily was worse in the past when she could turn head and feel it.
Appetite: hungry, no desire to eat.
BM: normal
Palpitations: no
Eyes: lights in front of her eyes sometimes
Menstrual cycle: way thru
Ear ring: no
Temp: colder than I should be, get cold easily used to be the hottest person in the room
Bleeding: none.
Worse: study, sit in class, think, moving, shopping, watching TV, listening to music.
Better: just laying in bed. Sacrocranial treatment helped her physical feeling, not energy.
Dark circles under her eyes, pale complexion.

Pulse

Thin, slippery, weak in first position, both sides. Mild wiry on left. Irregular rhythm rate can
change according to inhale/exhale inhale = faster, exhale = slower. Ask them to take deep, slow
breath and feel again. If speeds up, this isnt irregular or abnormal. More common in males
physiological sinoarrythmia.

Tongue

Pale, dusky, swollen. Vessels little distended and purple on edge. Crack in center, but not deep, not
a lot of coating building up around it.

Pattern Diff

Heart Blood Xu
Qi Xu (UJ/MJ)
Local Qi/Blood Stagnation

Disease Diagnosis

Poor memory

TX principles

Nourish Heart Blood, Tonify Qi in UJ and MJ, Move Qi and Blood locally.

Points/Therapies

Chase the Dragon GB 20(eyes of dragon), Du 14(mouth of dragon)

Jiaji points beginning T1 L5 unilaterally (start left side females)
Sishencong
Unilateral: SP3, GB 39, K4, BL 40 (China: Alzheimers oxygenates brain cells)

Needles used

Clinic Theater 2 Summer 2008

http://www.CatsTCMNotes.com
Page 1 of 2

Initials/age/gender
Chief Complaint
Current Assessment
and Related Histories

Leslie H follow-up visit

Residual aches, scar tissue adhesions
See Class 2 Notes for previous DX and histories

Hip replacement 4 weeks ago. Suture gone, doesnt need a cane to walk, but gets stiff after
sitting. If walk 8-10 blocks then walks much more easily afterwards. Doing PT, water and land
Still taking Vicodin daily. Not taking herbs
Sitting makes motility much harder!
L5 rotated because SI joint problems.
Low energy/motivation
Sleep diff with pain in pelvic girdle, radiating down right leg. Sleeps 8 hours or so.
Takes about an hour of mobility after waking before it feels better.
Lower leg edema when sitting. History of this especially in summer.
Grumpy in the evening
Night heat has turned to night sweat
Just finishing period right now.
Pain in leg has improved. Psoas muscle gets very tight, pain down quad line, glut med strained by
PT exercises. Also, with anterior hip replacement muscles attached to femur get torqued.
Lips pale
Pulse

Deep and slippery, weak in 1st/3rd positions

Tongue

Pale, swollen (some) teethmarks

Pattern Diff

Local Qi and Blood Yu (stagnation) - hip

Kidney Liver Yin Xu
Heart/Kidney Disharmony
General Qi and Blood Deficiency

Disease Diagnosis

Post surgical pain in right hip

TX principles

Move Qi and Blood in the local area

Tonify Kidney/Liver
Harmonize Heart and Kidney
General tonification of Qi and Blood

Points/Therapies

Surround the Dragon hip and scar tissue, GB 34/41

SP 6, LV 8, Ashi, ST 36, BL 62, K6/7, h3, SJ5, DU20
Recommend to use at home: Amber Massage Oil. Very strong, new product made by Spring Wind.
Good for bruises, sprain, moves the circulation. Also good for varicose veins. Can use as long as
there is no open wound. Once scar has healed, use.
Herbs: rebuild energy herbs

Needles used
Pain in scar area long after surgery: adhesion or surgical damage to nerve. Needle close to it, but not into it.
Can needle directly into ankle sprain swelling.

Clinic Theater 2 Summer 2008

http://www.CatsTCMNotes.com
Page 2 of 2