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Patient Initials: HAK

Initial Date of Patient Consult/Treatment: November 3, 2015
Patient Age: 55 Patient Gender: Female Occupation: Registered Nurse

Subjective Patient Complaints: Shortness of breath, abdominal pain, diarrhea,

fever/chills, fatigue, loss of appetite.
Onset: Patient revealed that she started having a stomachache that never went away about
a year ago. For the last 2 months, she started with all of the other symptoms and has lost
thirty pounds in the last year.
What provokes the symptoms? Nothing, it is always there. It never goes away or gets
better.
Quality of symptoms: Her symptoms have gotten so bad that she hasn’t been able to work
for the last month. She has been gone from work due to the pain and no strength to work
for long periods of time.
Is there any radiation of symptoms? Her whole-body aches and she feels no ambition to
do anything. No energy and very weak.
Describe the site of symptomology: Chest, Abdomen
Time of day/ duration of symptoms: The symptoms are always there, they never go away
Prior contributory health history: Healthy, has no previous health history to cause these
symptoms.
Characteristics of symptoms based upon Five Element Theory: shortness of breath caused
by low oxygen levels; abdominal pain is from her abdomen where further tests showed a
blockage in her intestine.

Objective Findings:
Diagnostic Testing Results:
Patient had labs drawn which showed severe dehydration and malnutrition. Went and did
a CT scan of her abdomen/chest which showed a large growth in her abdomen.
Medical diagnosis of Adenocarcinoma of the small intestine.
Patient went in for surgery to remove the growth in her abdomen. Labs showed that she
was dehydrated and started to give her fluids through her veins. Medication given for her
pain through her vein.

Working Diagnosis:
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Medical: Adenocarcinoma
Shortness of breath: Labs showed that she was dehydrated and also had a low red blood
cell count. She was given blood while in surgery and had a breathing tube in during
surgery. Once she was given blood and woken up from surgery, her breathing improved.
Abdominal Pain: Patient had surgery where they made a large incision down the middle
of her stomach to remove the growth from her intestine. The patient is being given pain
medication through her vein to help with any pain. As the wound heals, her pain should
improve.
Fatigue: Lab work indicated that indicated that patient was anemic and therefore gave her
two units of red blood cells which hopefully help with her tiredness. Patient also has been
diagnosed with cancer and is also another reason for being tired.
Loss of Appetite: Patient is not going to eat anything for awhile and will get her nutrition
through her veins until her stomach heals. Hopefully her appetite gets better and then we
will look at starting her on some supplements to help with her calories being taken in.
Adenocarcinoma: Will start chemotherapy on week 4 after surgery. No radiation is
recommended at this time.

Treatment Protocol:
A. Techniques used for treatment per session
Week #1
Treatment One: Patient was taken to the operating room for an emergency surgery to
remove the cancer that was blocking her intestines. After surgery she was in the hospital
for that first week getting all of her food through her veins while her stomach healed. She
was given pain medication and was able to rest a lot to help her heal that first week.
Week #2
Treatment Two: Patient is now taking some things by mouth and is drinking nutritional
supplements. She is taking pain pills to help with her pain and is no longer complaining
of shortness of breath. Patient has some loose stools but only 1-2 a day.
Week #3
Treatment Three: Patient is still in the hospital but is able to get up out of bed with no
help from the staff. She is eating and drinking and feels better. She is sleeping at night
and only sometimes needs medicine for her stomach pain. Her husband is there with her a
lot and she is planning on going home with him helping her.

Week #4
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Treatment Four: Patient started on chemotherapy today and did good without getting
sick. The plan is to do this every day for 2 weeks. During that time if she gets sick we can
put her back in the hospital or help her with any problems she has. Her stomach is healed
now and only a scar is there. Abdomen is soft. Her appetite is ok.
Week #6
Treatment Five: Patient finished all of her chemotherapy. Her hair has fallen out and she
was a little sick during the chemotherapy but did not have to come to the hospital. She
drinks more of her nutritional supplements than food right now but has not lost any more
weight. A repeat CT scan was done and there is not growth in her abdomen right now.
Her stools are still soft but no diarrhea.
B. Number of Treatments: 5 treatments over the course of 6 weeks.
C. Results: Patient no longer suffers from shortness of breath, some weakness from
chemotherapy but states that she feels better.
D. Comments from Patient: I hope we got all the cancer and I continue to get better
every day.

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