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Case Number: 14
Patient Initials: SUR
Initial Date of Patient Consult/Treatment: January 14, 2011
Patient Age: 65 Gender: Male Occupation: Office Manager

Subjective Patient Complaints: Has shortness of breath, cough and wheezing symptoms
that occur during physical activity or when he becomes anxious.
Onset: 4 years ago after he lost his wife from cancer.
What provokes the symptoms: any activity, cigarette smoke, perfumes, pollens. Notices
increased symptoms during seasonal changings.
Quality of symptoms: Feels tightness in his chest and notices that he wheezes when he
breathes. On a scale of 1-10, 10 being very painful, he rates his symptoms at a 7/10. He
states that his life is drastically changed since onset of symptoms.
Is there any radiation of symptoms? The coughing and effort to breathe makes him very
sore. He complains of neck and upper back soreness along with “tightness” in his chest.
He says his throat is often sore from coughing and is always sucking on a cough drop.
Describe the site of symptomology: Lungs, Throat, and his entire chest.
Time of day/duration of symptoms: Daily occurrences of shortness of breath where he
feels his symptoms are worse in the morning and at bedtime. He has trouble sleeping due
to coughing. Patient reports having to use medication (inhaler and nebulizers) at least 3-4
times a day to help with his symptoms.
Prior contributory health history: 1. Diabetic 2. Obesity 3. Smoking 4. Heart disease.
Characteristics of symptoms based upon Five Element Theory: A. Emotional grief
associated with not being able to be active due to shortness of breath and needing to be
on oxygen. He also states he misses his wife and has since become depressed after she
died. B. Skin is very dry with patches of irritated skin due to poor hygiene as he is unable
to bathe himself without becoming short of breath.

Objective Findings:
Diagnostic Test Results:
A. Patient presents a series of testing and reports from Brown Clinic to include:
a. Lab work-up
b. X-ray of heart and lungs
c. EKG
d. Stress Test
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In summary, the medical diagnosis of Adult Onset Asthma and Depression was given.
B. Shortness of Breath observed when sitting at rest. A different inhaler was given than the
one he was used to taking at home. Symptoms improved slightly.
C. Patient uses his abdominal muscles to breath and has his lips pursed together like he is
breathing through a straw. He breathes about 24 breathes a minute and is always hunched
forward as though he is fighting for a breath.
D. Patient is overweight with swelling noted in his lower legs. Scabs noted to arms and
lower legs.
E. Patient complained of chest tightness and had a chest x-ray and EKG completed to ensure
he wasn’t having any heart problems.
Working Diagnosis:
Medical – Adult onset asthma and depression

Treatment Protocol:
A. Techniques used for treatment per session
Week #1
Treatment #1: Lab work completed to see if he had any underlying conditions that may show
up on his blood work. Noticed that he was dehydrated but other than that, the only thing
elevated was his blood glucose indicating that his blood sugars were high and may be
diabetic. Started on an inhaler that will help him with his shortness of breath. Encouraged
him that his blood sugars were slightly elevated and that he should begin monitoring his diet
to make sure he is not eating foods high in sugar. Will follow up to see if he improves min
week 3.
Week #3
Treatment #2: Patient continues to complain of shortness of breath, his oxygen level is 88%
and it should be greater than 90% so I started him on oxygen at 2 liters to see if his shortness
of breath improves. The lower legs were a little swollen, so I started him on medication to get
rid of extra fluid. Patient continues to be sad during today’s visit, so I started him on a
medication to help him with his depression. I talked to him about his diet and he is trying to
cut back on sweets. His legs are still swollen with some scabs noted to his lower legs. He
started going to a support group to talk about his wife and meet other people that are feeling
the same way he is.
Week #5
Treatment #3: Patients is improving with his shortness of breath. He is taking his medication
that I started, and he has lost 5 pounds since his last visit. His legs are normal looking, and
the scabs have healed on his lower legs. He doesn’t look as though he is struggling to breathe
like he was before. He seems more relaxed and doesn’t fight to breathe like he was before.
He continues to go to his support group, and he has met another friend who also lost his wife.
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They are going to bible school on Sundays and he now has someone to talk to about his
feelings. He says he is doing better. His diarrhea seems to not be so bad.
Week #7
Treatment #4: Patient is feeling great and can do more activity around the house, including
bathing. He states that the medicine is helping with his shortness of breath. Educated him to
return if symptoms reappear otherwise, we will see him again for treatment when his
allergies become a bother for him again.
Number of Treatment: 4 treatments over a 7-week period. Patient is to be seen seasonally to
treat his symptoms and provide treatment as needed. Intensive therapy may be needed during
the spring and fall when he has the most symptoms from his seasonal allergies. He is to
continue to watch his diet and continue doing group therapy and if he continues to be sad, I
will begin him on some medication for depression.
B. Results: Patient no longer suffers from symptoms of asthma. He is watching his diet and
doing therapy to help with his mood.
C. Comments from patient: Pleased with his results after suffering for a long time. Looking
forward to being more independent and happier after meeting some people.
D. Personal comments from treating physician:

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