Chinese Medicine notes 04-03

From DmesWiki

TCM04-03 Oct. 1, 2005

How to take a history – how to elicit the information to allow you to help them. The only way to really learn is to do it. You learn how to do it in a short time and concisely. We’re going to combine a western and Chinese medical history. If you’re working with westerners, you’ll get western answers, so you need to elicit the right response.

You’re asking for information to get an idea of how their energetic imbalance is manifesting, like Sherlock Holmes – gathering information by observation and asking the right question. You have to be able to interrupt when necessary. Most of the time a person will tell you exactly what’s wrong if you listen and ask the right questions, and if you keep asking. If you don’t get it, go on to palpating, which is what you’ll be treating. What you feel by palpating is going to verify what you think from hearing.

Listen to both what they’re saying and how they say it. Listen for key words and tone of voice. We’ll learn a specific sequence for the history as well as for pulses, palpating the abdomen, etc.

Variables: chronic, multiple problems, acute new simple problems, etc. The short one is same as the long one, but leaving things out.

Ling shu=essential questions. When it started, how long, diet, etc.

Don’t prejudge or misjudge – don’t judge at all. Have an open-minded accepting caring attitude. If you make a quick judgement, you might miss something else that is there. With experience, you’ll know where to jump to in taking history. At first you have to take notes, not in whole sentences.

Outline: Western outline: 1: current complaint (cc) – the shorter the better, the energetic manifestation that’s bothering them now. It might be more than one thing, but you have to decide on the main one. If it’s unclear, try to clarify it.

2: present illness (many aspects) – this is most of the history. How they’re feeling wrt the current complaint. Ex.—“I feel like there’s a stick in my right temple.” When it started, exactly where it is, circumstances, does it happen a lot, what makes it better or worse, what have they tried, is it recurring, does it affect the rest of the body, does it change over time. If it’s chronic, ask how it affects the rest of their activities (gauge of severity).

3: past medical history – have they had this before, other past illnesses (related – have they had a neck injury, do they have new glasses, etc.), surgeries, strokes, diabetes, heart disease, chronic immunological problem, other illnesses, (things that would color the effectiveness of your own treatment) etc.

4: family history of medical illness – anyone else who has this too, recurring themes in the family – heart, stroke, cancer, etc.

5: review of systems (ROS) – western medicine is diff. from Chinese – systematically going through the organ systems and asking if they have problems in those areas. (see below for list)

6: social history – married (happy or not? Try to determine), career, smoking, alcohol, recreational drugs, what do they do for fun

7: diet history – “tell me what a typical day’s eating is for you”, what do you crave and what do you hate and why. Biggest cravings – salt, fat, sweet. In Chinese, you’re looking for how well they balance the five flavors, overeating salt, etc. Sour, bitter, sweet, pungent, salty.

8: sleep history – quality rather than amount – do you feel rested in the morning

9: exercise history – part of the lifestyle as other factors.

10: medication/vitamins – what they take, including herbs, homeopathic, etc. Listen for cumidin, which thins the blood so not good for needling. It also needs to be watched for when recommending diets, as the level is crucial and tends to shift.

Review of systems:

Do you have any chronic recurring problems with…?

Skin

lymph nodes (swollen, tender, removed),

bones joints or muscles, (recheck if they have arthritis

blood (anemic, too thick, transfusions)

endocrine system (thyroid, adrenal, ovaries, pituitary, etc.)

allergies, immune system

head eyes ears nose and throat (HEENT) – hearing loss, etc.

neck and spine – neck trouble, knee surgery, etc.

breasts – lumps discharges, etc.

respiration – now or past chronic breathing problems

heart or circulation – swelling, varicose veins, palpitations, etc.

GI tract, digestion – stomach, bowels, gall bladder

Genitourinary – discharges, infections, problems getting it to start, incontinence

Menstrual history – are periods OK, do you get PMS, any chance you’re pregnant, (if they’re pregnant, you’re treating two people and not one), etc.

Nervous system – seizures, stroke, dizziness or fainting, etc.

Mental health – depression, anxiety, fear, compulsions, difficulty coping, etc. Sometimes just asking will break down the barrier and they’ll realize it’s not something to hide.

By the time you finish the history, you should have an idea that their spleen is off, or something like that. If not, keep asking. If you know they have had a lot of illnesses, you want to do a thorough history, paying attention and taking notes. Make eye contact and ask questions that will result in them feeling heard. You can use their facial expressions to know when to interrupt. If you interrupt at the wrong time, go back and pick it up later.

History for an acute complaint:

Example sprained ankle.

All of previous history, plus:

1) exact location(s)

2) circumstances of onset, duration, recurrence, etc. (can be preceded by mental affliction or life circumstances)

3) association with movement – some pain wants to stay still and some wants to move.

4) association with tenderness – where, does it feel better or worse from pressure.

5) quality of pain – sharp, dull, deep, boring, throbbing, etc. to determine if it’s bone, nerve, etc

6) severity (1 doesn’t hurt -10 worst pain you can imagine)

7. characteristics – get them to describe it for you: sharp and shooting, deep and throbbing like inflamed tissue, constant or intermittent or recurrent, related to seasons, better or worse at which times of day, better or worse with activity or rest, related to position.

Part of our responsibility is to identify a problem that requires professional help. Three main things:

1. Unexplained weight loss – more than 10 pounds in 3 months without dieting, etc.

2. If there’s a chest complaint – pain, pressure, etc. ask if it gets worse with exertion to the extent that you have to stop.

3. If you ask about their bowels, and they say things have changed, ie. shape change, blood, etc., it can be a sign of something serious.

4. If they say it’s the worst headache of their life, it’s serious.

TCM History

1. current complaint

2. present illness *hot/cold – are you hot or cold? Has it recently changed? *Perspiration – is it appropriate? Cold and clammy, hot and sweaty, etc. The wei chi opens and closes pores, and if they aren’t doing it appropriately, we need to know. *head/body – yangness where chi is rising into meridians of the head (mostly yang). Ask how does your head feel, how is the rest of your body. *stool, urine – regularity, color, odor, quality, in the sense of changes from normal. *Diet – esp. cravings and aversions, keep in mind how it fits with meridian you think is out of balance. *Chest – respiratory, circulation, heart, digestion *hearing, vision, taste – changes, symptoms, etc., includes touch. *Sleep – quality, is it restful, do they have trouble falling (spleen) or staying (liver) asleep. *Thirst – how much liquid do they drink, do they drink when they’re thirsty, *pain – see below *emotion – as assoc. with current complaint: ask if they don’t volunteer. Also emotional condition of life – what do they do for fun, how is family life, etc. Specifically grief, fear, anxiety, joy, anger, pensiveness. Are you more mellow or do you fly off the handle. *working conditions – ask, because they won’t usually volunteer. Just asking will get them to think about it. *gyn (lady’s department; possibility of pregnancy) –

Pain

1. location

2. description of discomfort

3. possible cause

4. onset, time of worst and least pain

5. hot/cold – the area of pain and their sensation, fever w/or w/o chills. *what happens with pressure *does it make them want to stay still or move *is there swelling or does it feel like there is redness

Early on in a head cold, a person might have a fever and aversion to cold – pathogenic factor is just penetrating. Later, the aversion to cold goes away, and you get heat and runniness. If wei chi is strong enough it puts out the fire and stops the wind and sensations go away. If not, you get bronchitis or sinus infection as pathogenic factor goes deeper into the system. You have to check meridians to find out.

Perspiration – open the pores to relieve heat. This happens when we have healthy chi in metal element. If someone is sweating too much in the daytime, chi is failing to control the pores, so it’s chi or yang deficiency. Night sweats come from yin deficiency – yang isn’t in check and chi rises, pores open and heat comes out.

Fever with dry skin – depletion of blood and fluids (heat stroke).

Head and body – particularly yang meridians on head: gall bladder, bladder, SI and TE Shingles on head is sharp and shooting, but different from a headache. Usual causes in western med.s: muscle tension, vascular, combination of the two, tumors, meningitis.

There are more causes in TCM. Rule of thumb – severe headaches are excess condition. These come on rapidly and acutely. Dull chronic headaches are deficiency condition. Pains that are aggravated by cold, wind, heat are likely pathogenic factors having an influence on that meridian. They can start exterior and go interior. So if someone says they get headaches on a windy day, you need to look for an interior wind condition.

Pain that gets worse with heat is usually liver hyperactive yang – usually liver but sometimes TE. If it feels as if there’s a bag over their head or heavy head, it’s a phlegm damp condition – chi in that meridian is damp.

Headaches – frontal headaches = stomach and large intestine. Temporal headache – triple energizer and gall bladder. Headache in the back – bladder and small intestine. Pain at top of head=liver and pericardium. You could use P6 to treat.

Body symptoms – here we’re looking for pain or discomfort that they didn’t mention before, lumps, bumps or irregularities. You’re looking for things like one side weaker, pain on one side, etc.

Someone with general aching and no fever but chilled are coming down with an exterior condition. If there’s a specific location for pain or if the specific pain moves, it’s stagnation. Mild achey numbness and stiffness=chi and blood deficiency, failing to nourish the area, and you want to bring chi in. Heaviness and fatigue = dampness – thick, gooey chi that can’t flow nicely.

Stool and urine – painful urination = damp heat (infection), quality of digestion and bowels reflects spleen and LI. Constipation that is dry and pebbly = excess heat. Constipation without distention is from deeper problem of blood and fluid deficiency imbalance. Diarrhea = spleen or liver condition.

Diet – prefer hot or cold drinks, absence of thirst, cravings and flavors, appetite, are they bloated after they eat, how much food does it take to get to that point. People who tend to rich fatty foods are feeding damp heat or will get damp heat. Getting hungry soon after eating is a sign of heat in the stomach. Someone with a normal appetite but can’t digest has a strong stomach but a weak spleen.

Perverted appetites: eating dirt or ice = signs of anemia.

Taste in mouth usually reflects stomach. Bitter = heat, sweet = dampness or spleen deficiency, sour or putrid = stagnant digestate. Acid upflow = stomach heat or invasion of stomach by liver fire.

Fullness or swelling in chest or abdomen = excess condition. Where it is will tell you which meridian. Lateral = liver or maybe gall bladder stagnation. Oppression (feels like someone is sitting on it) = weakness or deficiency. If they are describing a sense of oppression, and they are having trouble breathing and look pale, dial 911 and give them an aspirin. You can squeeze their H1, P1, and GB26 if they will let you.

Abdominal pain. As a general rule for anything, a pain that improves with pressure is a deficiency, a pain that gets worse is an excess, a pain that improves with heat is cold condition, and a pain that gets worse is hot condition. A pain that moves is stagnation, wind or chi imbalance (if it stays in one meridian).

Ears are portals to the kidney. Vision is liver.

Homework – several histories.