TCM Case Work-Up

This page may be removed from patient intake form in order to work on. Work must be completed and
returned before the second visit. Patient name, first or last, should not be written anywhere on this page.
All reference to the patient is by assigned file number located on the patient’s folder.

Patient File Number: 020 Intern Name: Huiying Chin

Date of Treatment: Jan 14, 2022 Clinic Day/Time Friday 4.30pm Supervisor: Deguang He
60 F

MC1: Vertigo – poor balance, mild loss of memory, dizziness, walking as if drunk. All day today
and another this week. Worst this week. Daily episodes. Onset 6 years ago. Stress induced.
Pressure in her head. Audioneurologist to do tests in Feb 18. Triggered by sneezing, stress, light
and changing position. Taking meds to stop it.

MC2: Sciatica on left leg (connected to left lower back pain). 3/10 dull pain from hip to medial
thigh. Sometimes sharp for a few mins, random episodes, fixed position. Radiates tightness along
left thigh. Stretching relieves.

A year ago had swollen right calf and pain in one line that felt like right inner thigh was tight in
one line. Near liver and spleen channels. Left calf pain above ankle was achy, felt like a sprain,
stiff and tight.

Recently diagnosed with torn right knee miniscus. No swelling except a year ago. Pain goes
away, unrelated to movement. Not tried heat.

Temperature normal, no abnormal sweats. Sometimes warm flashes at night.

No headaches, just pressure in back of head during MC1, lightheaded, wobbly and drunk.
All day tinnitus high-pitched worse on the right.
Family moved out, no exercise recently
Good appetite 2-3 meals, poor appetite today, no gas or bloating. Diagnosed with GERD,
sometimes chest tightness. Diagnosed 7 years ago.

BM 1-2x daily, formed. Normal thirst and urination.

Stress: low after son’s family moved out
Musculoskeletal: see MC2
Sleep: Easy to fall asleep, after 4 hours, hard to fall back asleep, exhausted around 9pm.

Pulse: Good width at medium level, regular, 78 bpm, wiry on right, thin on left.
Inspection: Patient is lean, fit, average height and weight, good shen.

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Diagnosis: Channel stagnation in BL, LV channels, wind in jueyin channel, LV and KD yin
deficiency.

MC1 – Vertigo – Anchor and tonify yin, calm wind in channels

MC2 – Sciatica– Course qi in channels and relieve stagnation

Pool of points, adjunctive techniques: with clear reasons for using each, what method and what
adjunctive techniques will be used:
LU7+KD6 – Ren to support insomnia, tonify lungs and kidneys
TW5+GB41 – Dai mai and yang wei for balance
LV 8 – tonify LV yin and blood
LV5 and GB 40 – Host and Guest combo for GB channel
Electro: BL40- and GB30+
Si Shen Cong – for Vertigo
BL15 – tonify HT
BL18 – Harmonize LV
BL19 – Harmonize GB
BL20 – tonify SP
BL23 – Tonify KD
CV4 – tonify yang and qi – moxa on needle
CV6 – tonify qi
DU20 – raise clear yang
Yin tang – calm shen
HT 5 – Treat vertigo and dizziness
KD3 – tonify kidneyes
SP6 – tonify yin and blood, supports sleep
Auricular: Ear Shen Men, point zero, hip, forehead and temple area for vertigo

Prognosis: Good, patient is active, open to herbal formulas and eats healthy.
Treatment plan: Weekly treatments for 5-6 sessions and evaluate

Explanation of Diagnosis:
Due to old age, the patient is yin deficient in KD and LV. With light sleep and mediocre appetite
and diet, patient is blood and yin deficient. Blood deficiency leads to wind in the jue yin channels
of LV and GB. As the yin cannot anchor the yang, there is vertigo and warm flashes.

Blood deficiency in LV channel also led to channel stagnation in LV and BL/GB channels in lower
limbs.

Headache, dizziness, vertigo, tinnitus, sighing, sudden loss of consciousness, or possibly

expectoration of blood. Dysfunction of the liver in spreading and precipitating qi; Reverting liver
qi

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Pale face and tongue, dizziness, vertigo, tinnitus – LV blood deficiency
Ascending of liver fire may cause headache, vertigo, syncope and vomiting of blood.
Liver blood deficiency manifests failure of the liver in regulating blood and subsequent
malnourishment of the relevant zang–fu organs. The main contributing factors include
insufficient production of blood, loss of blood and chronic conditions consuming liver blood. It
generally involves liverrelated symptoms of a systemic blood deficiency. Clinical manifestations
Vertigo, tinnitus, dry eyes, blurred vision, poor vision or night blindness, a pale lusterless or
sallow complexion, numbness or tremor of the hands and feet, muscle spasm or twitching, dry
nails, scanty menstruation in a pale color, amenorrhea, pale lips, a pale tongue with a thin
coating and a thready pulse.

Pathogenic factors attacking the du meridian may cause opisthotonos, stiffness of the neck and
back, trismus, headache, convulsions of the four extremities, coma, fever, a white or yellow
tongue coating and a wiry or rapid pulse. Deficiency of the du meridian may cause dizziness, a
heavy sensation of the head, vertigo, a poor memory, tinnitus, deafness, lumbar soreness and
weakness, rickets, a pale tongue and a thready weak pulse.

Migrating pain – stagnation of the flow of qi in the channels and network vessels
Fixed pain – stagnation of the flow of blood in the channels and network vessels
Radiating pain – obstruction in the flow of qi
Chronic pain – Insufficiency of qi, blood or yang, obstruction of blood circulation

Pain with limited range of motion and aggravated at night: Qi and blood stagnation leading to
blockage of channels and network trauma history vessels – Qi stagnation and blood stasis

Treatment Principle based directly on above diagnosis (include a treatment principle for each
MC/SC):
Vertigo – Tonify yin and blood. Anchor the yang and calm wind.
Sciatica – Relieve pain by coursing stagnation in channels and sinews

Citation in support of diagnosis:

Information/quote, Author, Book Title (italics), Edition (if applicable), City of Publisher: Name of
Publisher; Year of Publication, (page numbers)
Chen Ping, Diagnosis in Traditional Chinese Medicine, Taos, New Mexico, Complementary
Medicine Press, 2004 (Vertigo 202-209, 163) (70-73 pain)
Hong-zhou Wu, Zhao-qin Fang, Pan-ji Cheng, Chou-ping Han, Introduction to Diagnosis in
Traditional Chinese Medicine, Hackensack NJ, World Century Publishing Corporation, 2013 (269
Vertigo)
Xue-mei Li, Jingyi Zhao, Acupuncture Patterns and Practice, Seattle, WA, Eastland Press, 2012, (79,
Vertigo)

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Treatment Plan: #_5_of treatments for #5 of weeks, then re-evaluate.

Prognosis: Good, patient is active and motivated to eat healthy and try herbal formulas. But the
conditions are both chronic and will take longer to see clear results.

Research Article Summary (Article 1)

Title Efficacy and safety of acupuncture for dizziness and vertigo in emergency
department: a pilot cohort study

Author/s Chih-Wen Chiu,# Tsung-Chieh Lee,# Po-Chi Hsu, Chia-Yun Chen, Shun-Chang Chang, John.

Y. Chiang, and Lun-Chien Lo

Journal BMC Complement Altern Med.

Publication Date 2015 Jun 9

Abstract
Background
Dizziness and vertigo account for roughly 4% of chief symptoms in the emergency
department (ED). Pharmacological therapy is often applied for these symptoms, such as
vestibular suppressants, anti-emetics and benzodiazepines. However, every medication
is accompanied with unavoidable side-effects. There are several research articles
providing evidence of acupuncture treating dizziness and vertigo but few studies of
acupuncture as an emergent intervention in ED. We performed a pilot cohort study to
evaluate the efficacy and safety of acupuncture in treating patients with dizziness and
vertigo in ED.
Methods
A total of 60 participants, recruited in ED, were divided into acupuncture and control
group. Life-threatening conditions or central nervous system disorders were excluded to
ensure participants’ safety. The clinical effect of treating dizziness and vertigo was
evaluated by performing statistical analyses on data collected from questionnaires of
Dizziness Handicap Inventory (DHI), Visual Analog Scale (VAS) of dizziness and
vertigo, and heart rate variability (HRV).
Results
The variation of VAS demonstrated a significant decrease (p-value: 0.001 and p-value:
0.037) between two groups after two different durations: 30 mins and 7 days. The
variation of DHI showed no significant difference after 7 days. HRV revealed a
significant increase in high frequency (HF) in the acupuncture group. No adverse event
was reported in this study.
Conclusion
Acupuncture demonstrates a significant immediate effect in reducing discomforts and

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VAS of both dizziness and vertigo. This study provides clinical evidence on the efficacy
and safety of acupuncture to treat dizziness and vertigo in the emergency department.

Application to your case (Article 1)

How might you incorporate the information in this article into your care of the patient? (at
least 300 words)

Experiment group received acupuncture at Zusanli (ST36) and Neiguan (PC6) acupuncture
points, ref. Fig. 1 [12]. Single-use, sterile, 40 mm × 0.25 mm, silver-handled needles (An-Chi
disposable acupuncture needle, made in Taiwan) with guide tubes were used. Needles
were inserted at correct acupoints and manually stimulated until the ‘De Qi’ sensation was
elicited according to TCM protocol [13]. The needles stayed in place for 30 min. The control
group received sham acupuncture by pasting seed-patches at non-acupoints. The non-
acuponits were displaced by 1 cm from correct acupoints of experimental group. The
therapist did not perform any massage or press stimulation to prevent acupressure effect.

I want to include these two points in my point prescription and also consider using the
questionnaires they used in the research about patient’s lifestyle.
Factors to observe: smoking history, hypertension history, body mass index, blood
pressure. They measured how dizziness affected the patient’s daily living – balance,
walking, changing, appetite and so on. I want to engage my patient in understanding how
she is managing her episodes of vertigos and what acupressure she can do at home to treat
herself.

Dizziness Handicap Inventory for reference:

Does looking up increase your problem?  Because of your problem, do you have difficulty
getting into or out of bed?  Do quick movements of your head increase your problem? 
Does bending over increase your problem?

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 Research Article Summary (Article 2)

Title Efficacy and safety of acupuncture for chronic dizziness: study protocol for a
randomized controlled trial

Author/s Zhe Xue, Cun-Zhi Liu, Guang-Xia Shi, Yan Liu, Zhao-Xin Li, Zhen-Hua Zhang
& Lin-Peng Wang

Journal Trials

Publication Date Dec 2013

Key Findings (at least 200 words)

Background
Dizziness is one of the most challenging symptoms in medicine. No medication for
dizziness in current use has well-established curative or prophylactic value or is suitable
for long-term palliative use. Unconventional remedies, such as acupuncture, should be
considered and scientifically evaluated. However, there has been relatively little
evidence in randomized controlled clinical trials on acupuncture to treat chronic
dizziness. The aim of our study is to evaluate the efficacy and safety of acupuncture in
patients with dizziness.

Methods/Design
This trial is a randomized, single-blind, controlled study. A total of 80 participants will
be randomly assigned to two treatment groups receiving acupuncture and sham
acupuncture treatment, respectively, for 4 weeks. The primary outcome measures are
the Dizziness Handicap Inventory (DHI) and the Vertigo Symptom Scale (VSS).
Treatment will be conducted over a period of 4 weeks, at a frequency of two sessions per
week. The assessment is at baseline (before treatment initiation), 4 weeks after the first
acupuncture session, and 8 weeks after the first acupuncture session.

Discussion
The results from this study will provide clinical evidence on the efficacy and safety of
acupuncture in patients with chronic dizziness.

Application to your case (Article 2)

How might you incorporate the information in this article into your care of the patient? (at
least 300 words)

According to the research design:

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Interventions
Patients who meet the inclusion criteria and none of the exclusion criteria are randomized
to one of two treatment groups. Group A will receive acupuncture in the Baihui, Yintang,
Taiyang, Tinggong, Wangu, Fengchi, Hegu, Fenglong, and Taichong acupuncture points
(Table 1). Single-use, sterile, 40 mm × 0.25 mm or 25 mm × 0.25 mm (depending on the area
to be treated), silver-handled needles (HanYi disposable acupuncture needle, made in
Tianjin HuaHong Medical Co., Ltd., Tianjin, China) without guide tubes are used. Needles
are correctly inserted and manually stimulated until the ‘De Qi’ sensation is elicited. The
needles will stay in place for 30 min and will be manually stimulated every 10 min. Only
needle acupuncture will be allowed: other forms of acupuncture treatment (for example,
laser acupuncture, electro-acupuncture, or moxibustion) will not be permitted.

So, I plan to incorporate their points into my pregscription:

Baihui DU20, Yintang, Taiyang, SI 19 Tinggong, GB12 Wangu, Fengchi GB20, Hegu LI4,
Taichong LV3

They also mentioned the Vertigo Symptom Scale as a progress measurement. I want to
incorporate some of the questions into my follow up intake.
Vertigo-balance subscale score (VSS-sf-V)

1 A feeling that either you, or things around you, are spinning or moving, lasting less than
20 minutes

3 Nausea (feeling sick), vomiting

4 A feeling that either you, or things around you, are spinning or moving, lasting more than
20 minutes

6 A feeling of being dizzy, disorientated or swimmy, lasting all day

8 Unable to stand or walk properly without support, veering or staggering to one side

10 Feeling unsteady, about to lose balance, lasting more than 20 minutes

13 Feeling unsteady, about to lose balance, lasting less than 20 minutes

15 A feeling of being dizzy, disorientated or swimmy, lasting less than 20 minutes

Autonomic-anxiety subscale score (VSS-sf-A)

2 Hot or cold spells

5 Heart pounding or fluttering

7 Headache, or feeling of pressure in the head

9 Difficulty breathing, short of breath

11 Excessive sweating

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12 Feeling faint, about to black out

14 Pains in the heart or chest region

Total score (VSS-sf-T)

Research Article Summary (Article 3)

Title Effectiveness of Acupuncture for Treating Sciatica: A Systematic Review and Meta-
Analysis

Author/s Zongshi Qin, 1 , 2 Xiaoxu Liu, 1 , 2 Jiani Wu, 1 Yanbing Zhai, 1 , 2 and Zhishun Liu 1 , *

Journal Evid Based Complement Alternat Med. 2015; 2015: 425108.

Publication Date 2015 Oct 21

Key Findings (at least 200 words)

Abstract
This is a systematic review and meta-analysis, which aimed to assess the current evidence
on the effects and safety of acupuncture for treating sciatica. In this review, a total of 11
randomized controlled trials were included. As a result, we found that the use of
acupuncture may be more effective than drugs and may enhance the effect of drugs for
patients with sciatica, but because of the insufficient number of relevant and rigorous
studies, the evidence is limited. Future trials using rigorous methodology, appropriate
comparisons, and clinically relevant outcomes should be conducted.

Sciatica is a syndrome involving nerve root impingement or inflammation that has

progressed sufficiently to cause neurological symptoms in the areas that are supplied by
the affected nerve roots [1]. The most important symptoms include unilateral leg pain
radiating to the foot or toes that is greater than low back pain and often associated with
paresthesia, numbness, and weakness of the leg; it may involve increased pain on straight
leg raising and neurological symptoms limited to one nerve root. Sciatica may be sudden in
onset and may subsequently persist for days or weeks [2, 3].

Frymoyer reported that the prevalence of sciatica varies widely from 13% to 40% [4, 5].
According to the research of Konstantinou, most patients suffered sciatica in the fourth and
fifth decades of their life [6]. The treatment for sciatica is primarily aimed at pain control by
means of either conservative treatment or surgical techniques. According to the prior
systematic review, nonopioid medication, epidural injections, and disc surgery are effective
for pain reduction [7]; however, relevant side effects to epidural injections have been
reported [8–10], and the effect of NSAIDs on sciatica is still uncertain, even though it is a

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common treatment to manage pain. Many patients report little relief [7], and the surgical
procedures are invasive and expensive and may even cause neurological complications
that may not be acceptable for all patients [11].

Application to your case (Article 3)

How might you incorporate the information in this article into your care of the patient? (at
least 300 words)

In general, all of the studies adopted a treatment theory based on traditional Chinese
medicine theory and clinical experience. Many acupuncturists choose acupuncture points
or corresponding acupuncture interventions based on their clinical experience during
treatment. Electroacupuncture was used in most of the trials (6 studies) [20, 23–25, 28, 30],
warming acupuncture was used in 3 studies [21, 27, 29], and manual needle stimulation
was performed in 2 trials [22, 26]. The number of acupuncture points varied from 1 to more
than 10; the most commonly used acupoints were Huantiao (GB 32), Weizhong (BL 40), and
Yanglingquan (GB 34). The acupoints for each trial are shown in Table 4. The duration of
interventions ranged from one to four weeks and only one trial mentioned 6 months of
follow-up. The age of the patients ranged from 18 to 79 years. Eleven studies reported De-
chi, a needle sensation of soreness and numbness.

Acupoints of each trial.

Wang and Huantiao (GB 30), Weizhong (BL 40)
La 2004 [20]

Chen et al. Shenshu (BL 23), Dachangshu (BL 25), Huantiao (GB 30), Weizhong (BL 40),
2009 [21] and Kunlun (BL 60)

Zeng 2012 Huantiao (GB 30), Zhibian (BL 54), Chengfu (BL 36), Fengshi (GB 31),
[22] Weizhong (BL 40), Yanglingquan (BL 67), Chengshan (BL 57), Xuanzhong
(GB 39), Kunlun (BL 60), and Zulinqi (GB 41)

Zhang et al. Jiaji (EX-B2), Yaoyangguan (DU 3), Huantiao (GB 30), and Yanglingquan
2008 [23] (BL 67)

Hu et al. Yaoyangguan (DU 3), Shiqizhui (EX-B7), Huantiao (GB 30), Yanglingquan
2010 [24] (BL 67), Weizhong (BL 40), and Chengshan (BL 57)

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Du et al. Jiaji (EX-B2)
2009 [25]

Chen 2010 Jiaji (EX-B2), Zhibian (BL 54), Huantiao (GB 30), Yinmen (BL 37), Weizhong
[26] (BL 40), Chengshan (BL 57), and Kunlun (BL 60)

Wang 2008 Jiaji (EX-B2), Zhibian (BL 54), Weizhong (BL 40), and Yanglingquan (BL 67)
[27]

Meng 2014 Jiaji (EX-B2), Huantiao (GB 30), Juegu (GB 39), Weizhong (BL 40), and
[28] Zhibian (BL 54)

Ren 2013 Dachangshu (BL 25), Shenshu (BL 23), Mingmen (DU 4), Guanyuanshu (BL
[29] 26), Qihaishu (BL 24), Zhibian (BL 54), Huantiao (GB 30), and Jiaji (EX-B2)

Zhao 2004 Huantiao (GB 30), Weizhong (BL 40)

[30]

I will try to incorporate some of these points into my prescription and measure progress.

Biomedica How does the patient’s biomedical diagnosis inform your approach to
l treatment?
Diagnosis

(For example, are there any points or herbs you are avoiding? Are there ways in which
the patient is limited in the types of treatment they can receive? Are there ways in
which you are coordinating care with other treatment providers?) (at least 200 words)

Patient’s history of GERD means we have to be careful in the herbal prescription and
interaction with her medication. I suggest that if any herbs is prescribed, she has to take
them separate from current meds.

I want to see if acupressure can help relieve her vertigo that she can delay or reduce her
reliance on the vertigo medication. I think I need her to consult her PCP to make sure
there is a strategy that we can implement effectively with minimal disruption to her life.

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