Date:

July 25, 2008

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Patient
KP, female, 30 yo. Massage therapist
Chief Complaint:

Intermittent cricks in the neck and pain in AS joint for three to five years

Intermittent feelings of frustration and sadness

Course: Clinic Theater 2

Class #: 1

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History:
Cricks in the neck
Three to five year history. Has tried massage therapy, chiropractic. Her shoulders are
rounded and she says the musculature here is loose and doesnt hold the bones tightly.
Also, broke her rt clavicle in childhood and another therapist told her he thinks there
could be a slight structural difference in level of right and left. Chiropractor dx = stuck
facet joints.

Has not had a CT or MRI.

Hands are not tingly. Has a sharp grabbing sensation that shoots to her head, sometimes
giving her a headache more often on right side than left.

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Frequency: 2 times per month to different degrees, sometimes wakes with it and happens
most often in morning.
Stretching and hot showers improve condition.
(Dr. Shen: probably a muscle spasm, causing bone movement and crimping the nerve)

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Frustration
Doesnt feel impatient, but stuck and has problems motivating herself to get going. Tried
a life coach about a year and a half ago which helped. Also, has some sadness, grief, loss
from the death of a family member about 3 months ago.

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Interestingly, liver health has been on her mind.

Anger is internalized, doesnt express exteriorly. Face when frustrated gets red and
mottley. Does not have a metallic taste in her mouth. When frustrated, feels heat in her
head, but no dizziness. Occasional headches.

Energy

Good energy in the morning, in good humor after a shower. Energy drops when she sits still and
it is difficult to get herself moving again. Gets tired and is ready for bed at 10:30pm.

Sleep
Easily gets to sleep, says she sleeps OK. Shes a flipper and sometimes talks in her sleep.
Sometimes has a thought she cannot get out of her head so she will lean over and verbalize it to
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her husb. Usually is a to-do list item. Gets up 1ce or so to go to the bathroom. Feels rested
upon waking. Dreams, but only remember the sensation of dreaming, not vivid dreams.

Appetite is good. Liquor intake is minimal.

Bowel movements: 2 3 times per day
Urination: no problems

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Menstruation
On birth control pills, not heavy mens, very regular.
Period started on Tuesday of this week and is almost over now.

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Digestion
Is aware that she hold stress here.

Pulse

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Deep, slippery. Weak in the 3rd position.

Left side is much weaker.

Dr. Shen: Women are often more wiry, slippery. Usually weaker and thinner after their periods.
Before the period the pulse will often surge.

Tongue
Red. Looked dark with a purplish tint to me, but Shen says is dusky red with a thin white coat.
She said she had blueberries today for breakfast about 1.5 hours ago. Ah.

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Dr. Shen: When you eat your tongue can be colored by 1) the pigments in the food, 2) by the
motion of the tongue during eating which makes it redder, 3) by the nature of the food if
heating, the tongue may get redder.

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Disease Diagnosis:
None for the occasional neck cricks. This is a symptom, not a disease in and of itself.
For the frustration, this is called Yu Syndrome which encompasses bipolar, depression, anger,
anxiety and grief.

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Differentiation:
Liver Qi Stagnation. (frustration)
Local Qi and Blood Stagnation (neck spasms/cricks)
Note from Dr Shen: Stagnation can cause heat in the body. Compare stagnation to standing
water. Standing water is much warmer in temperature than running water. Heat in the body can
come from stagnation for the same reasons if the Qi is flowing the body is cooler. KP does
have some heat signs, but once the Qi stagnations are resolved, then the heat should resolve too.

Treatment:
Soothe Liver Qi, Move Qi and Blood.
Possible Points: LV 3 + LI 4 (soothe liver, move qi and blood), GB 34 (spreads LV qi and
soothes tendons and sinews), LU 7 (command pt for head/nape, pre-treat grief/sadness), SI 3
(open Du and neck), HT 7 (regulate Shen to help with emotional probs), Du 20 (headaches,
tongue redness and LV yang rising on occasion), LU 3 (treats grief and sadness WOS point)

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Shens Lecture

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Regarding Chief Complaints

Rules:
1. Be concise and informative
2. Be descriptive rather than conclusive or diagnostic
Examples:

Dont say allergies, but itchy eyes with intermittent nasal congestion for 3 months

Dont say hypertension, but high blood pressure with dizziness and vertigo for 2 years

Dont say digestive problems, but gas and bloating for 3 weeks

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Basically, its a thesis sentence like in a high school english paper. Give enough information to describe
the problem concisely.

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TCM Disease Diagnosis and Differentiation

This is not a Western disease dx such as hypertension, UTI, URI, etc. TCM dx would be stuff like
edema, headaches, wasting thirsting disease, Bi syndrome, Yu syndrome.

There is a difference between the differentiation and the diagnosis. As an example, Wind Heat Invasion
(W/H Invasion)is a differentiation. Headaches as a result of the W/H Invasion would be the diagnosis.
One can experience W/H in many forms such as headaches, neck stiffness, nasal congestion. The TCM
disease diagnosis expresses what form the pattern differentiation takes.

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Other examples of TCM Disease Dx: Leukorrhea with discharge, Diarrhea (with a differentiation of
W/H invasion for example). We will learn more about this in Acupuncture Treatment of Disease and
Herbal Treatment of Disease.
Keep diagnosis simple. Less is more. Use as few diagnoses as possible to explain the pts situation.
Describe what causes this problem. When this resolves it will clear up satellite problems.

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Side Bar:
Remember not to base your whole Dx on the tongue or pulse, but on the whole picture. Also
remember the Pts chief complaint and address this rather than something you see that looks
more problematic to your TCM trained mind. Remember that if a person comes in with knee
pain and you see strong evidence of Kidney Qi deficiency, theyll never come back to get the Qi
deficiency taken care of if you dont help them with the knee problem!

Using KP as an example, her pulse is weak in the 3rd position as well as overall which according
to the charts would indicate Kidney and Blood xus. The interview doesnt show this, however,
nor did the other assessments. Leave this diagnosis out of the chart unless there are other
supporting evidences of the dx. Another thought, while it is true she is probably blood deficient,
remember that shes at the end of her menstrual cycle which would explain the blood xu.

Also recall that pulse may be rapid, usually indicating heat, but it can be due to circumstances
such as rushing to the clinic, anxiety about being at the doc, having a bad day, etc. Rapid is
relative, also. 60-90bpm is considered clinically normal.

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Regarding blood loss at menses, can gauge this by the number of pads or tampons the patient
uses. Can also base dysfunction on whether menstruation makes the patient fuzzy headed,
renders her incapable of work or normal daily activities. These are indeed dysfunctions, but
menstruation itself is not a disease!

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Another thought before you write down that disease diagnosis. Once a stressor or causative
factor is removed, does the problem persist? As an example, last trimester I was having very
vivid dreams and occasional palpitations. I initially thought I had a heart deficiency, but as it
turned out I was just way stressed out. Once the semester was over my sleep was normal and no
more palpitations. In KPs case, shes got some grief, yes, but its due to the loss of her
grandmother. Its not affecting her Lung or Liver and if all is basically normal in her emotional
world, the grief and sadness will probably resolve over time. No need to include that in the DX
either.

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Treatment Principles
Should be consistent with Diagnosis and Differentiation. Treatment principles reflect your belief
in your diff and dx. Treat this first. Try to use points with multiple functions. Go for simple and
straightforward. Again, less is more. By old tradition, most treatments used no more than about 5
points!

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Regarding Needles
Shen uses DBC needles in multipacks of 10. He uses .16mm - .18mm x 30mm (1.5 cun) as his
house needle. They are Korean made, are very sharp, are coated to minimize pain and make
insertion easier. They run about $19 per 1000, dont bend or break and have metal handles so
you can use them for electro stim.
If you want stronger stimilation, go for the Chinese needles which are less sharp and are not
coated. These are the best for pain treatment and paralysis.

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Since these needles come in 10 packs, you have to plan your needling better if you need more
than a multiple of 10 (like you need 22 needles), then use the 10 in the pack and switch to
singles.

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If you only need 7 needles and have 3 left over, per CNT, you can use those 3 needles on another
patient or in another treatment as long as 1) you use a new guide tube for each patient and 2) you
use those left overs within 24 hours of opening.

Regarding clean fields

You need a flat, clean, dry surface per CNT. Doesnt have to be a table. You can carry a tray
with a clean papertowel on it around with you as a portable field as long as you do not
contaminate.

Regarding sharps containers

Sharps are only for sharps!! Dont toss in your trash or even your bloody cotton balls. Govt regs
for hospitals say you dont have to dispose of bloody fibrous waste (gauze pads, cotton balls, etc)
in hazardous waste unless they are dripping with goo or will drip if squeezed. This doesnt apply
to most of the cotton balls we use even if were doing a bleeding procedure. Moral to the story:
toss em in the trash.

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