New Patient
Intake
Written by Chris Eddy
When deciding on formulas, we need a clear diagnosis.
To get a clear diagnosis, we need a very clear and detailed intake.
To get a good intake and to understand the intake, we need to SEE what’s gone wrong in the body. Abnormal physiology.
To do this we need to be organised. The more ways we can lay out the info, the better. Graphs, pictures, shapes, explanations and timelines all help.WARNING: This is a REALLY LONG way of doing things, and there’s no way anyone is going to do this for each patient. However, I find this is a great way to really look at a case (especially the really tough cases) and break it down.
The order is:
1.Intake
2.Symptom Analysis
3.Signs and Symptoms Overview
4.Diagnosis
5.Overview in Pictures
6.Timeline
7.Explaining What Happened
8.Treatment Principle
9.Explain The Formula
Intake: Tell the story
Here’s where you paint a picture of the patient.
Example Case: CC: Pompholyx Eczema and Chronic Constipation
Patient is a 38 yo female, 5ft, slim build (50 kg), with persistent constipation since around 8-10 yo after hospitalisation for 3 months. Stool is often dry, hard and passes every 1-2 days, and also has pompholyx eczema.
Emotionally the patient is a “stressed, perfectionist”.
Pompholyx eczema started after wearing a nickel ring 10 years ago. Skin gets worse when feeling hot and stressed. Skin is very dry, cracked, itchy, red-pale (erythema when acutely bad/pale when just dry and itchy) and fissured. Much worse after giving birth and breast feeding. Better when relaxed and when on holiday.
Feels tired all the time, even before giving birth. Skin very dry all over and taut.
Patient HATES the heat, gets hot hands and feet day and night, especially when tired. Also prone to dizziness and Benign Proximal Positional Vertigo (BPPV) especially after milk and cheese.
Drinks 2-3 glasses of wine per day. Doesn’t drink much water as not thirsty for water, it doesn’t quench.
Very tight muscles. Chronic back, neck pain. Back pain feels weak.
Urination every 30-60 minutes, clear.
Face can also get eczema around eyes. Eyes are often puffy and swollen, face can be swollen. Skin on face and lips always dry.
Symptom Analysis
Constipation: stool not easy to pass
Worse With: Stress: Liver Involved
Dry: Dryness in large intestine
Pompholyx Eczema: skin issue on hands
Itchy skin: Wind on hands
Cracked/Fissured Dryness on hands
Worse With: Jewellery: Worse with jewellery
Washing hands: dry hands
Dry Weather: Dry Hands
Stress: Liver Involved
Breast Feeding: Fluid Deficiency
BW: Holiday: Less stress improves
Moisturizer: Moisture Helps
Feels hot all the time: Heat accumulation
Hot hands and feet: Deficiency Heat
Lack of thirst: Fluids not moistening mouth
Dry Skin All over: Fluids not reaching surface
Dry Lips: Fluids not moistening lips
Swollen eyes: Fluids accumulating around eyes
Swollen face: Fluids accumulating in face
Abd pain below umbilicus: Excess pain below umbilicus
Low energy: Low energy
Low blood pressure: Low blood pressure
Dizziness/BPPV: Fluid/Damp in upper jiao
Tongue
Swollen body: Fluid Accumulation
Red Tip: Heat in upper jiao
Pale edges: Liver Blood deficiency
Teeth marks: Fluid accumulation
Dip in middle and back: Kidney deficiency
Red prickles at front: Constrained heat
Pulse: Overall “Excess”. The excess comes from liver being blocked. All excess comes from something being blocked, so here the liver is not opening through and is blocked. So there is a ‘pent up’ feeling. Although this patient is overall deficient, there is a build-up of fluids and liver qi that is creating excess signs.
Signs and Symptoms Overview
With many signs and symptoms, you can put them all on one page here to have an over all view.
Diagnosis
Kidney and Spleen Qi Deficiency
Damp accumulation
Depressive heat
Dryness in general in the Large Intestine
Blood Deficiency
Liver Qi Depression
Overview in Pictures
What we are actually seeing is poor processing of fluid, liver depression and heat not circulating properly.
Time Line
1985: Hospitalized for micoplasma for 3 months – multiple medications. Constipation since this point.
2008: Wore Nickel ring and eczema on hand started
2017: Gave birth, breastfeeding
2018 / March: Skin flared up
Explaining What Happened
Dryness: Water in the wrong place (due to kidney and spleen qi deficiency). Water is leaking out through urine and not going back into intestine. Depressive heat from liver heating blood, drying skin.
Dampness: Sp and Kid Qi deficiency – flesh not holding and absorbing water
Constipation: Dry fluids, water in wrong place, leaking out through urine, depressive heat leading to heat in Yang Ming.
Hot hands and feet: Depressive heat from liver, Qi xu not holding Yang, fluids not steaming.
Treatment Principle
Open and move liver qi
Clear dampness and fluid
Nourish Blood
Cool blood and stop itching
Explain The Formula
Chai Ling Tang (XCHT + WLS) + Shen Qi Wan
- Chai hu 15
- Huang Qin 12
- Zhi Shi 12
- Gan Cao 9
- Shi Gao 30
- Mu Dan Pi 9
- Ze Xie 12
- Bai Shao 48
- Bai Zhu 36
- Rou Gui 12
- Rou Cong Rong 12
- Sheng Di 20
- Dang Gui 12
Bai Shao 48 (because of extremely tight muscles and constipation)
Si Ni San (CH, ZS, BS, GC)- great for deficiency constipation
Shi Gao – to vent heat in hands and yang ming
Chai Hu – to help move and relieve depressed liver
Ze Xie – to drain ministerial fire
Bai Zhu – At triple dose 36g to help fluids back in flesh and balance fluids in the wrong place.
Rou Cong Rong – tonify kidneys and moisten the bowel
Sheng di – 20g to cool blood and nourish yin
Dang Gui – To nourish blood
