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Good Morning Everyone. Here is the case for Wednesday’s case study. Please remember to be prepared with questions to further your understanding of the case, suggestions for assessment and treatment strategies, as well as herb and formula suggestions.
Case Study Class 20 November 2024
Gender: male
Age: 36
Height: 6’ 0”
Weight: 215 lbs
Ethnicity: American
Occupation: VC/consulting
Chief complaint: anxiety, nervousness, sense of tension as if curled up in a ball
Symptoms: difficulty staying focused, general anxiety, mental and physical tension
Brief history: traumatic childhood with a raging father, over-achiever, high-stress occupation
Diet and Lifestyle: Eats a pretty healthy diet, alcohol occasionally, but previously used it to “help social interactions” or to avoid feeling bad. Gets some exercise, recently has lost ~75 lbs (actively trying to lose weight via dietary choices and exercise). Recently filed for divorce to get away from a toxic relationship.
Sleep: fair to poor (5-6 hours). Wakes frequently, dreams, difficulty falling asleep, wakes early in the morning.
Energy: good, in spite of challenging sleep quality, seems to have good energy
Appetite: no hunger
Stool: 1 X/day (occasionally misses a day)
Thirst: “normal”
Urine: 3–4 X day
Basic observations: Patient is in good health, overweight but losing weight appropriately, health improving with dietary and exercise modifications. Also seeing an acupuncturist and therapist.
Pulse: deep, thin, difficult to find in all by the upper burner positions
Tongue: stiff, pointed, reddish/purple, thin whitish-yellow coating