Case Study with Thomas

Responses

1. 

   Thomas July 23, 2024

   For: Advanced Students working on Case Studies. If you are not actively working on the advanced lessons and case Studies, you can still attend, but please stay in listen only mode, unless called upon.

   Preparation:

   1. What other questions might you ask?

   2. A diagnosis using Chinese medicine or Western Herbal Medicine

   3. A treatment strategy based on the diagnosis

   4. An appropriate formula

   【Case Study Class 19 June 2024 】

   Gender: male

   Age: 62

   Height: 192 cm

   Weight: 115 kg

   Ethnicity: white American

   Occupation: US government

   Chief complaint: GERD*, type II diabetes, coronary artery disease, acute myocardial infarction, hypertension, difficulty sleeping (*diagnosed by dietician but patient doesn’t think it is good diagnosis.)

   Symptoms: occasional heart burn after eating, wakes many times during night, prefers cold drinks and foods (and winter)

   Brief history: Formally got a lot of exercise, but over the last decade that has declined significantly for a variety of reasons.

   Diet and Lifestyle: eating better now with lots of room for improvement. Still eating sweets after lunch and dinner.

   Sleep: poor, needs to get up to pee 4–5 times a night, struggles to fall asleep as well

   Energy: not very good but seems to be able to work and get on with his day, even though he clearly has fairly low energy

   Appetite: strong, recently trying to reduce sweets/snacks, eating more healthy

   Stool: 1 X/2–3 days, hard and difficult

   Thirst: often thirsty

   Urine: 7–10 X day

   Basic observations: Patient is in fair to poor physical health, although mentally he seems to be is average or above health, this is a good thing because he clearly wants to work on his health, even if it is obvious that he is a little down about his current situation. Patient has been trying lots of things by trying to learn from the internet but finally realized that he needed to talk to a professional because he wasn’t getting the results that he desired and he finally realized that it was more complex than he might have thought.