Jacob Wolf Shoulder Pain Case Name: HT Age: 29 Gender: Male Occupation: Student First Visit CC: Shoulder

and neck pain HPI: HT has had a longstanding shoulder injury, starting in 1999, from playing baseball. His past diagnoses include 2 labrum tears, multiple shoulder dislocation, and rotator cuff damage,. He had surgical repair in 2002 with anchors placed to prevent future dislocation and allow continued use for sports. HT had nerve damage initially which has resolved. He has noted pain with barometric changes. Additionally, he believes his pain is exacerbated by stress. The pain feels like a pulsing, mostly in back around scapula with areas tender to touch. He has decreased ROM and constant tightness in his shoulder. His shoulder pain will often lead to neck tension and occipital headaches. PE: Vitals: BP: 131/76, Pulse: 59, Resp: 12, Temp: 97.9F Tongue: Red body, thin white coating. Significant sublingual stagnation. Pulse: wiry and slippery TCM Diagnosis: Qi and Blood Stagnation Western Diagnosis: Left labrum tear, rotator cuff repair, shoulder anchors for chronic dislocations Acupuncture Points SH- 2 needles- wiggle All Unilateral SI3, Ligue, Da Bai ST38- 2 needles on tender spots GB39, UB60, UB62Wiggle LV3- wiggle SI9, LI 15, 14, 11, Jian Qian SI10, 11, 12, GB 21, 20, SJ14, SJ3 Shoulder Ashi points Second Visit: CC: Shoulder and neck pain

HPI: HT returned for his second visit largely improved. Shoulder has been feeling better, but has felt a little sore in the neck. Shoulder loosened up immediately after treatment, this is something that he has not felt in many years. He now rates his shoulder pain as 0/10. Has now had some tightness in neck, like ropes. Feels like his neck is taking some of the burden of his shoulder being looser. Drinking water and stretching his neck/shoulder helps the pain. PE: Vitals: BP: 127/78, Pulse: 64, Resp: 12, Temp: 98.7F Tongue: Red body, thin white coating. Mild sublingual stagnation. Pulse: wiry and slippery Same protocol was used: Acupuncture Points SH- 2 needles- wiggle All Unilateral SI3, Ligue, Da Bai ST38- 2 needles on tender spots GB39, UB60, UB62Wiggle LV3- wiggle SI9, LI 15, 14, 11, Jian Qian SI10, 11, 12, GB 21, 20, SJ14, SJ3 Shoulder Ashi points