Patient Profile:

My notes

Patient Profile:

Age: 60 years old

Occupation: Businesswoman

Primary Complaint: Constipation for the past two years

Lifestyle:

Engages in a well-balanced lifestyle with daily gym sessions, swimming twice a week, and other activities.

Diet rich in vegetables and fruits, with adequate water intake.

Takes a significant dosage of supplements.

Vital Signs:

Blood Pressure: 101/80 mmHg

Heart Rate: 55 bpm

Tongue and Pulse Diagnosis:

Tongue Coat: Yellowish tint noticed after consuming avocado and kiwi fruits; otherwise, tongue coating was normal.

Tongue Body: Presence of teeth marks and cracks.

Pulse:

Left Pulse: Thin pulse, indicating weak Kidney Yin.

Right Pulse: Thin pulse, indicating weak Kidney Yang.

Additional Notes:

Patient reports satisfaction with the treatment, with no constant pain but occasional transient discomfort.

Diagnosis indicates a pattern of Yin deficiency.

TCM Diagnosis and Treatment Plan:

Diagnosis: Qi Stagnation with Yin Deficiency

Treatment Principle: Move Qi and promote fluids in the Large Intestine.

Treatment Methods: Acupuncture, Ear Seeds

Acupuncture Prescription:

ST25 (Tianshu): Front-Mu point of the Large Intestine, used to regulate bowel movements.

Needle Depth: 1.0 to 1.5 cunAngle: Perpendicular insertion.

LI4 (Hegu): Promotes the movement of Qi, especially useful for constipation associated with stagnation.

Needle Depth: 0.5 to 1.0 cunAngle: Perpendicular insertion.

SP15 (Daheng): Strengthens the Spleen and regulates the intestines.

Needle Depth: 0.5 to 1.0 cunAngle: Perpendicular or slightly oblique insertion towards the lateral side.

BL25 (Dachangshu): Back-Shu point of the Large Intestine, regulates the intestines and relieves constipation.

Needle Depth: 1.0 to 1.5 cunAngle: Perpendicular insertion.

ST37 (Shangjuxu): Lower He-Sea point of the Large Intestine, promotes bowel movements and clears damp-heat from the intestines.

Needle Depth: 1.0 to 1.5 cunAngle: Perpendicular insertion.

KI6 (Zhaohai): Used for constipation associated with Yin deficiency and dryness.

Needle Depth: 0.3 to 0.5 cunAngle: Perpendicular insertion.

ST36 (Zusanli): Tonifies Qi and blood, harmonizes the stomach and intestines.

Needle Depth: 1.0 to 1.5 cunAngle: Perpendicular insertion.

Number of Treatments: 4

Diet and Lifestyle Advice:

Continue staying hydrated by drinking plenty of water.

Engage in gentle exercises like walking, yoga, and Tai Chi to help manage stress and support digestion.

4o

looking, hearing, smelling, palpation, asking,

In Traditional Chinese Medicine (TCM), the Four Diagnostic Methods are essential for gathering information about a patient's health condition. These methods are:

Looking (Observation):

Tongue Diagnosis: Observing the color, shape, size, coating, and movement of the tongue to assess internal conditions.

Facial Observation: Checking the complexion and any visible signs on the face.

General Appearance: Noticing the patient's posture, gait, and overall demeanor.

Hearing and Smelling:

Hearing: Listening to the patients voice, breathing, cough, and any other sounds they make. The tone, strength, and quality of these sounds can provide insights into the state of the organs.

Smelling: Detecting any unusual body odors or breath, which can be indicative of specific imbalances or conditions, such as dampness, heat, or food stagnation.

Palpation:

Pulse Diagnosis: Feeling the pulse on both wrists to assess the condition of the internal organs. The pulse can reveal information about the strength, rhythm, and quality of the Qi and Blood.

Palpation of the Body: Feeling different areas of the body, especially along meridians and acupuncture points, to detect any tenderness, swelling, or other abnormalities.

Asking (Inquiry):

Asking about Symptoms: Inquiring about the patients main complaints, including pain, digestion, sleep, emotional state, and other relevant symptoms.

Asking about Lifestyle and History: Gathering information on the patients diet, exercise, work habits, and medical history, including any previous treatments and their outcomes.

University required

ASSESSMENT INFORMATION

Case History (3000 words) 20% of your course mark

This assignment assesses Learning Outcome 1 and 3. You are required to write an academic case history selecting a client you have treated. Submission is through your Moodle classroom. Academic case histories provide a level of focus, critical thought and reflection about clinical practice that goes beyond documenting a treatment story or anecdote. Written to a high standard they provide an opportunity for publication and add to the evidence base for Chinese medicine. Although western medicine case histories have a focus on unusual cases or illustrating areas of concern, Chinese medicine has a long history of using case histories to focus on learnings for clinical practice. Highlighting discussion of treatment rationales and possibilities, observation of treatment outcomes, providing information for future treatment directions, and opening up relevant discussion for students and practitioners. Although a single case history cannot claim cause and effect, in a modern context they can also be used to: Demonstrate the successful application of theory in clinical practice. Present a lesson learnt you wish to pass on to colleagues /other practitioners. Raise questions about theory or the application of theory in a clinical situation. Present patterns of disharmony seen in clinic that differ from the usual textbook presentations. Present uncommon medical conditions that have presented in clinic. Report on adverse reactions to acupuncture and/or Chinese herbs or the interaction between Chinese herbs and pharmaceuticals to raise awareness amongst other practitioners. Present patterns that appear confusing and/or contradictory, that created treatment dilemmas. Reflect on the therapeutic encounter, diet and lifestyle advice and patient compliance and the effect on the patients treatment outcomes. Report on the use of validated outcome measures in a clinical setting. Describe an encounter with an unusual or unexpected outcome. It is an important part of your case history that rather than just telling a story of your treatment, it demonstrates critical thought and reflection and concludes with at least one take-home point for those reading your case study to consideResources

Required

1. Deadman, P., and M Al-Khafaji. 2007. A Manual of Acupuncture. 2nd ed. East Sussex: Journal of Chinese Medicine Publications 2. Maciocia, Giovanni. 2015. The Foundations of Chinese Medicine: A Comprehensive Text. 3rd ed. Churchill Livingstone 3. NZSATCM. Handbook of Clinical Policies and Procedures. Wellington: NZSATCM. Recommended 4. Maciocia, Giovanni. 2005. The Practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbs. 2nd ed. Edinburgh: Churchill Livingstone. Page 3 of 9 5. Maciocia, Giovanni. 1995. Tongue Diagnosis in Chinese Medicine. Revised. Vista, California, United States: Eastland Press Inc. 6. Shen-Qing, Li, and William Morris. 2011. Li Shi-Zhens Pulse Studies: An Illustrated Guide. Peoples Medical Publishing House 7. CMCNZ Practice Standards: https://www.chinesemedicinecouncil.org.nz/Public/Public/Practitioners/PracticeStandards.aspx?hkey=b2f97f0d-e093-42bf-b066-c171dff0fede

Cultural Competency and Safety

(These courses are free, and certificates are awarded for proof of CPD) 1. Foundations of Cultural Competency https://learnonline.health.nz/course/view.php?id=184 2. Understanding Bias in Health Care (1hr) https://learnonline.health.nz/totara/catalog/index.php?catalog_fts=understanding+bias 3. Compliance with Te Tiriti o Waitangi requirements in Ng Paerewa Health and Disability Services Standard NZS8134: 2021 (1hr) https://learnonline.health.nz/enrol/index.php?id=551 4. Disability Equity (30 mins) https://learnonline.health.nz/totara/catalog/index.php?catalog_fts=Disability+EquityResearch Resources Tick H, Nielsen A, Pelletier KR, Bonakdar R, Simmons S, Glick R, Ratner E, Lemmon RL, Wayne P, Zador V; Pain Task Force of the Academic Consortium for Integrative Medicine and Health. Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper. Explore (NY). 2018 May-Jun;14(3):177-211. doi: 10.1016/j.explore.2018.02.001. Epub 2018 Mar 1. PMID: 29735382.

Academic Dishonesty

Academic dishonesty means using someone elses work as your own work or allowing others to represent her/his work as their own. The acts of dishonesty relating to assessment include: plagiarism, unauthorized collaboration, and examination misconduct.

Plagiarism

Plagiarism is defined as not acknowledging a source of information or using other peoples ideas as your own. This includes work that has been copied or adapted from a printed or internet source. When using another persons work or ideas, you must correctly cite or quote the source using the Vancouver referencing style.