Course: Clinic Theater 2

Class #: 4
Initials/age/gender
Chief Complaint
Current History

Date:

8/15/08

TR, 27yo, male

Chronic posterior/anterior muscular pain, left shoulder for 7yrs, aggravated for 6 weeks.
Stress
Feels like shoulder pain is related to stress, not being able to let go. Tends to get worse w/diet,
stress craving dark choc, expresso, beer since Summer Solstice. Craving bitter/sweet. Feels like
it might be reld to the heart channel.
Pain= 3/10 most of the time, sometimes up to a 7/10 during the day.
E-stim makes it worse.
Havent tried heat lamp.
No western med treatment/dx.
Pain not assoc w rest or activity
Pain not assoc w weather.
Last tx was 8/08 cupping and needles.
Energy: tired , energy at about a 3/10 in the evenings. Low lately, 8/10 usually, now 6/10.
Sleep: erratic. 5-6 hours a night for several weeks. Pain doesnt prevent sleep, but with less sleep =
more stress.
Palps? Not in a while
Sigh a lot? Sometimes
Cry? No, but want to.
Emotion: not angry, has been in past.
Digestion: energetic fullness around Ren 12, cant breathe sensation sometimes as a result chest
tightness. Ab spasms when trying to relax gets very intense if he tries to let it go.
BM: 2-3/day, slight loose
Concentration/thinking: cloudy, unfocused, cant think as clearly, less motivation to study

Past History
Pulse
Tongue
Pattern Diff
Diagnosis
TX principles
Points/Therapies

10 yrs ago recurrent injury erector spinatus muscles mid back btwn T4 and 7
HX of dampnesscd be grabbing the Qi, but no current sx.
Wiry, a little choppy (not bad enuf to fx interior), weak in the 1st.
3rd and 2nd are strong.
Pale, a little purple on edge. Under is dusky.
Qi and Blood stagnation with Liver overacting on Spleen
Move Qi and Blood, soothe LV, tonify SP
Cats votes:
Cupping may be the best tx for muscle spasms.
4 gates
ST 36, SP 6, GB 34
Local points for shoulder front/back palpate for exact ones.
Shens votes:
BL 62, SI 3
4 gates for Liv Qi Yu
SP 6, ST 36, P6, Ren 17/12, GB 41/34
Cupping

Needles used

Interior more than exterior

Excess more than deficient . If deficient pain, hurts more with use, energy drop = worse pain. Emotional
stress = tighten muscles is also more excess.
Shen suspects heart mind restlessness, though not a lot of sx to back that up.

Clinic Theater 2 Summer 2008

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

Shen Chat
Gas/bloating are signs of Qi stagnation in MJ, not of deficiency. But the Qi stag in MJ could be because
of xu.
Followup
DJ followup from last week said tx helped, hes taking yoga and its helping. Tightness in chest
come and goes. Some improvement. Energy has improved some. Shen recommended more tx for
him. Dont know if he did it.
KM report (TK and I txd): definite improvement after tx.
TRs herbal formula:
Going for powder since hes traveling this weekend. Shao Yao Gan Cao Tang (15g - relax
muscles on back/diaphragm, nourish LV), Gan Mai Da Zao Tang (12g - emotion soothe), Xie
Bai (xpand Qi in MJ), Xuan Fu Hua (6g), He Huan Hua(7g). Hou Po (6g), Yu Jin (6g). Chai Hu.
3g TID

Charting again, new topics:

ICD-9 code is the number for diseases. Used for insurance claims and documentation. Insurance co
doesnt understand liver qi stagnation. ICD is est by WHO, used by all to describe disease and sx
treated. Use more codes for sx than for dx in TX practice. Acupuncture family council puts out a long
binder with most of these codes, most needed for acupuncture. Also some free online databases.
Software for acu clinics Client Tracker by Gingko Software. There are lots of them out there, Shen
says this is a good one. Has ICD-9 codes built in too.

Clinic Theater 2 Summer 2008

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