Case write up examples
On the left you will see what a finished protocol can look like followed by some explanations, on the right you can read the client background info and results:
Protocol: Client x
Decoction of following herbs:
Dipsacus: 6 grams decoction. (anabolic, analgesic, blood mover, specific for tendons)
Rehmannia: 2 grams (anabolic, blood builder, yin tonic to balance dipsacus)
Licorice root slices: 2 grams decoction (demulcent, immunomodulator, analgesic/anti-inflammatory, liver harmonizer)
Make 1 weeks decoction supply at once and keep in fridge. Decoction instructions in separate e-mail/phone call.
Black cohosh in gelcap 5:1 extract: 600mg daily (anti-vata specific for osteoarthritis, benefits menopause symptoms)
Bio-K+ Probiotics: Follow instruction on bottle.
Fish liver oil: 4 pills of Carlson Cod Liver Oil (anabolic source of omega-3's + vitamin A, 2400 mcg, to benefit joint pain)
Ginger: 3 grams total with meals in gelcap divided by three meals. (warming, blood mover, analgesic/anti inflammatory, immune, hepatoprotective)
Reduce maximum coffee intake from 6 cups to 4 cups a day. (relax and heal, stop stimulating sympathetic nervous system)
Any questions about ANYTHING will be answered on phone upon request.
End of protocol--------------------
Analysis:
Symptoms appear vata dosha but with inability to exercise causing weight gain.
Digestive system may be damaged by antibiotics causing indigestion.
Joint pains appear to be more osteoarthritic in nature than rheumatoid.
Possible deficiency in vitamin A, can be cause of joint pains.
Goals to be achieved within 30 days:
Bring down pain of Achilles tendon to be able ride bike for 6 miles before pain, instead of 4 miles.
Bring right hand/wrist pain from hurting 25% of time to 15% of time.
Reduce indigestion to occurring 0-1 times/week instead of 0-2 times/week.
Reduce amounts of sneezing from 10 a day to 5 a day average.
Herbal properties/actions in protocol:
Decrease vata (amavata joint pain)
Blood movers (joint circulation)
demulcent (dry vata)
Analgesic/Anti-inflammatory (pain)
Anabolic (joint tissue)
Warming (vata pain, digestion)
Probiotics (gut health)
Immunomodulator ("hay fever" like symptoms) Harmonize liver (TCM tendons associated with liver, also benefits migraine)
Harmonize liver (TCM tendons associated with liver, also benefits migraine)
Client Background: osteoarthritis, tendonitis. Client x
55 year old woman 5‘4“ 139 pounds.
Experiencing menopause with hot flashes and night sweats for 10 years. Works as a nurse, married twice, 2 children. Dry skin, tends to feel cold.
Complaints: Joint pain in left knee (35 yrs), low back pain on right side(31 yrs), big toe (20 yrs), right wrist (less on left wrist, 2 yrs), Achilles tendon (6 months). The pains started with left knee which is attributed to uneven leg length. Back pain started while pregnant with 2nd child. Hands started to hurt due to writing at job. Achilles tendon pain has caused a decrease in exercise and has increased body weight within the last 6 months. She has a 60% reduction in exercise. She has been seeing a physical therapist for last 2 months. Body pains are worse in cold weather.
Also has indigestion, “sour stomach” feeling 0-2 times/week.
Diagnosed with migraine which started 22 years ago after moving to different state with kids and worried about finance while peri-menopausal. Migraine manifests on average once a week.
Diagnosed hyperthyroidism which led to removal of thyroid 30 yrs ago which is no longer hyper, very minor scoliosis of spine, tendinitis in wrists/hand and left knee, tendonosis in Achilles tendon, minor and non-intrusive eczema with dry skin flaking off on palms of hands.
She has self diagnosed herself as having hay fever due to 10 sneezes a day and runny nose for most of life.
Family history: Alcoholism runs in family and lost father to it who also had colon cancer. Grandmother had pancreatic cancer and mother currently has dementia.
Medications:
In past has taken antibiotics about 15 times, including 2 months ago for root canal. No probiotics afterwards besides daily yogurt.
Currently takes:
Levothyroxine 100 mcg/day for thyroid hormones.
Excederine for migraine (2 tablets as needed, once/week average)
Sumatriptan for onset of migraine (50 micrograms, once/week average)
Diet includes about 10% meat, 30% veggies, 20% fruit, with wheat, grains, and cheese for most meals. She snacks on nuts (5% of diet) and eats ice cream 3 days a week.
2-6 cups of coffee a day (helps with migraines), 1 glass of wine a week.
Has 3-4 bowel movements a day with rare diarrhea.
6-8 hours of sleep a night.
Results:
Client reported back after a few months of protocol with Achilles tendon pain no longer a problem but left with inflammation in wrist, no more indigestion, decrease in hot flashes, decrease in sneezing. After discontinuing the herbal protocol anti-inflammatory techniques were explained to her such as celery juice. The next few days after juicing celery she reported her wrist inflammation has been reduced to manageable, but could still be improved. Client has not asked for a second consultation.
What kinds of questions are generally asked to determine a protocol?
Case Study - X
1/23/2018
42 year old male
5'8"
187 pounds
Not married, no kids, long time girlfriend.
Sales clerk
Complaint: 2 years of chronic hiccups: Frequent, random occurrence although sometimes after food and commonly followed by burps (which causes social "stress"). Also common occurrence after exercise for hiccups to become louder.
Constitution/Vikruti: Kapha excess. Slow metabolism. Overweight.
Medical History: Said nothing significant, no diagnosis.
audience feedback
Current medication: None except occasional Tylenol in rare cases.
Diet: Processed foods, wheat, dairy, meat, 4-5 servings of fruits and vegetables weekly.
Exercise: Hiking once a month average, walking every other day, occasional weight lifting once a month. Not very active.
Emotional: Content with life in general. Kapha mind (Manas Prakruti). No serious signs of stress.
Auudience feedback
Goal: Noticeable reduction of hiccups within 2 weeks (based on clients perspective).
Herbal actions: downward moving energy, enhance digestion, speed up metabolism, anti-kapha, antispasmodic for diaphragm.
Vata condition that is aggravaed by kapha, because hiccups are inherently vatta. (Apana vayu blocked by kapha in digestive tract, sending back upwards)
Herbal protocol: 1 tablespoon ginger powder or fresh ginger incorporated into food. 1 teaspoon cayenne pepper incorporated into food daily as well.
Dietary: Recommended spicy food in general if he does not end up following the herbal protocol. Recommended eating apples, bananas and cardamom tea because of the downward energetic movement thought to help hiccups (didn't express specific amount because this person seemed to be slow to change diet, although now i realize i should have recommended 1 serving a day of each).
Started protocol around 1/25/2018
Audience feedback
Reported back: 2/4/2018
He only took ginger and cayenne and increased spicy food in general:
Says "spicy food has been helping", less frequent hiccups. Satisfied with results, although condition is not completely resolved. Agreed that cutting back on processed foods and fatty foods could help.
New goal: Stop hiccups from being a chronic condition 100% within 1 month.
New suggestions: Eat 4 ounces of yogurt with 2 teaspoons of salt mixed in when hiccups start. If that does not help then take 1 tablespoon of sugar by itself. Reduce greasy foods.