what do you write in a Medical Record
- general information: name, gender, age, marital status, heritage, birthday, address, phone, profession
- main symptom & duration
- history of present disease
- patient’s past medical history (including life style and habits)
- family history
what are the 4 methods of diagnostic examination?
- observation (wang)
- auscultation and smelling (wen)
- interrogation (wen)
- pulse feeling and papation (qie)
what are the 10 inquiries?
- cold and heat (chills and fever)
- perspiration (abnormal sweating)
- head and body
- urination and defecation
- diet and taste
- sleep
- hearing
- thirst
- anamnesis: cause of disease
- medical history
* special question to women (mensturation), children (vaccines), about life styles, hobby, drugs, alcohol, sexual activity
Cold can be classified by what two categories? What are their characteristics?
aversion to cold (sudden & temporary)
intolerance to cold (constitutional, always cold in general)
what are the 4 types of Cold and Heat encountered clinically?
- aversion to cold and elevation of body temp
- intolerance of cold w/o fever
- only heat, w/o cold
- alternate spells of cold and heat
what are the 3 general exterior syndromes that belong to “aversion to cold and elevation of body temp”?
- exterior cold syndrome: serious aversion to cold and mild fever
- exterior heat syndrome: serious fever and mild aversion to cold
- attack of wind on Tai Yang: mild fever, aversion to Wind, and spontaneous perspiration
what are 2 general interior cold syndromes which belong to “intolerance of cold w/o fever”?
- intolerance of cold due to internal damage, protracted illness, or the debility of Yang. this is generally a Deficient syndrome
- intolerance of cold due to an attack of cold on internal organs, such as ST, Intestines, etc. This is generally an excessive syndrome.
“Only Heat, w/o Cold” is commonly encountered in interior heat syndrome, explaine
- High Fever
- Tidal Fever:
a. tidal fever due to Damp-Heat
b. tidal fever of Yang Ming - protracted low fever
a. low fever due to deficiency of vital energy
b. low fever due to deficiency of Yin or Blood
what is “alternate spells of Cold and Heat”?
- half-exterior and half-interior syndrome of Shao Yang
2. Malaria
what can cause abnormal sweating?
both exopathic attack and internal damage may cause abnormal sweating, such as hyperhidrosis, anhidrosis, etc
what are the 4 interior syndromes differentiated according to state of perspiration?
- spontaneous perspiration
- night sweat
- trembling perspiration
- perspiration due to collapse of yang
what are general causes of the various types of perspiration?
- spontaneous perspiration _______
- nigh sweat ______
- trembling perspiration ______
- perspiration due to collapse of yang _____
- qi or yang deficiency
- yin deficiency (
3.
what is night sweating?
suddenly waking up bc of sudden sweat
all happens in minutes, NOT continuous sweating
what is trembling perspiration?
difficult sweating, fighting to expel EPF. you feel better after you sweat bc you expel the pathogen
what does perspiration on forehead generally indicate?
usually yangming
what is hemi-hidrosis?
half body sweat, usually after stroke
what is perspiration at palms and soles?
when you have damp-heat, palm and sole (the inside yin) has more heat
what are the 3 general characteristics of pain in (head and body) do you ask about?
- properties: sharp, dull, burning sensation…
- duration
- burning
what are the pathogenesis and clinical pattern of pain due to obstruction?
pathogenesis: any material pathogens such as blood clots, urinary stones, food stagnation cold, heat, dampness accumulation
clinical pattern: Excess
what are the pathogenesis and clinical pattern of “Pain Due to Poor Supplementation”
pathogenesis: insufficiency Qi and Yang leading to poor warmth, or insufficiency of Blood and Yin, resulting in poor Nourishment
clinical pattern: Deficiency
what are the treatment plan for excess and deficient pain, which results in blockage?
in excess clinical pattern, you ned to move and expel the blockage
in Deficiency, you tonify and nourish
give the pathogenesis and clinical patterns of each manifestations
- distending pain: Qi Stag, Excessive
- stabbing pain: Blood stasis, Excessive
- migrating pain: Qi Stag, Excessive
- fixed pain: Blood stasis, Damp, Excess
- gripping pain: Qi, Blood stasis, Excess
- vague pain: Deficiency, Deficient pattern
- hollow pain: Def, Def pattern
- pain with cold sensation: Excess Cold or Def Cold, Excess or Def pattern
- pain with burning sensation: Excess Heat or Deficient heat, Excess or Def pattern
- pain with heavy down-bearing: Dampness, mixture excessive and deficient pattern
what is duration of pain for excess and deficient pain pattern?
Excess pattern - sudden onset, acute pain
Deficient pattern - gradual onset, chronic
what are the 3 headaches due to external pathogenic attack?
- headache due to wind-cold
- headache due to wind-heat
- headache due to wind-dampness
