Herbal Practice Exam – Clinical Case Study #4

CASE 1

Use the following information to answer questions (1 to 2):

Joe is a 52-year-old stockbroker who is quite high up in his company comes into your clinic limping. When he sits down, he takes off his right sock and you observe that his toe is red and swollen.

Patient Information:

• he screams out in pain with light palpation
• the problem appeared 2 nights ago
• patient is unaware of the cause
• patient is overall healthy
• patient has stress and overworks
• he drinks many glasses of red wine/night
• meat consumption is high, especially red meat

Question 1: What is the TCM Illness?

CASE 1

Use the following information to answer questions (1 to 2):

Joe is a 52-year-old stockbroker who is quite high up in his company comes into your clinic limping. When he sits down, he takes off his right sock and you observe that his toe is red and swollen.

Patient Information:

• he screams out in pain with light palpation
• the problem appeared 2 nights ago
• patient is unaware of the cause
• patient is overall healthy
• patient has stress and overworks
• he drinks many glasses of red wine/night
• meat consumption is high, especially red meat

Question 2: What is the most likely biomedical impression for this patient?

CASE 2

Use the following information to answer questions (3 to 4):

A 72-year-old woman comes to your clinic complaining of upper back pain.

Patient Information:

• it is an ‘aching’ pain
• general feeling of weakness in her low back
• low energy
• lack of strength
• very slim
• Caucasian female
• mild Dowager’s hump in her upper back
• drinks about 3 coffees/day and 2 soda pops (long-term)
• rarely exercises

Question 3: What is the most likely biomedical impression for this patient?

CASE 2

Use the following information to answer questions (3 to 4):

A 72-year-old woman comes to your clinic complaining of upper back pain.

Patient Information:

• it is an ‘aching’ pain
• general feeling of weakness in her low back
• low energy
• lack of strength
• very slim
• Caucasian female
• mild Dowager’s hump in her upper back
• drinks about 3 coffees/day and 2 soda pops (long-term)
• rarely exercises

Question 4: Once referred to Western medicine, what kind of testing do you think she would undergo? (Select 2)

CASE 3

Use the following information to answer questions (5 to 6):

A 42-year-old male comes to your clinic with the complaint of difficulty in swallowing his food.

Patient Information:

• throat feels tight/constricted when he swallows for the past 4 months
• patient took Tums a few times/day until they stopped working
• doctor put him on Pantoloc which ‘helps a bit’, but he went off it a couple of years ago because he didn’t like the thought of being on a medication
• acid regurgitation especially at night when he lies down
• bitter taste in his mouth quite often
• ST and esophagus burn for about 10 years

Question 5: What is the TCM illness?

CASE 3

Use the following information to answer questions (5 to 6):

A 42-year-old male comes to your clinic with the complaint of difficulty in swallowing his food.

Patient Information:

• throat feels tight/constricted when he swallows for the past 4 months
• patient took Tums a few times/day until they stopped working
• doctor put him on Pantoloc which ‘helps a bit’, but he went off it a couple of years ago because he didn’t like the thought of being on a medication
• acid regurgitation especially at night when he lies down
• bitter taste in his mouth quite often
• ST and esophagus burn for about 10 years

Question 6: What is the happening here in terms of Western pathology?

CASE 4

Use the following information to answer questions (7 to 8):

A 33-year-old new mom comes to your clinic. She just had her baby 2 weeks ago and says that she is having trouble emptying her bladder since.

Patient Information:

• fullness in hypogastrium
• frequently feels like she needs to void, but when she sits on the toilet, it either doesn’t come, or just small amounts come out after a bit of waiting
• pallor
• dizziness
• coolness
• fatigue
• low back ache since her long labour
• Pulse: Weak (Ruo)
• Tongue: pale with tooth-marks on the sides

Question 7: What is the name of her TCM Illness?

CASE 4

Use the following information to answer questions (7 to 8):

A 33-year-old new mom comes to your clinic. She just had her baby 2 weeks ago and says that she is having trouble emptying her bladder since.

Patient Information:

• fullness in hypogastrium
• frequently feels like she needs to void, but when she sits on the toilet, it either doesn’t come, or just small amounts come out after a bit of waiting
• pallor
• dizziness
• coolness
• fatigue
• low back ache since her long labour
• Pulse: Weak (Ruo)
• Tongue: pale with tooth-marks on the sides

Question 8: What is her TCM syndrome differentiation?

CASE 5

Use the following information to answer questions (9 to 11):

Jake is a 14-year-old boy who just came back from traveling abroad with his parents on a tropical vacation. At the end of the vacation, he started having severe stomach cramps and lots of ‘very smelly’ diarrhea.

Patient Information:

• occasional blood in the stool
• pallor
• fatigue
• lips are parched
• diarrhea feels “hot” coming out
• feels very unwell
• nauseous
• achy
• forehead is hot
• Pulse: Rapid (Shuo) and Slippery (Hua)
• Tongue: red with a thick, yellow greasy coat

Question 9: What is the name of his TCM Illness?

CASE 5

Use the following information to answer questions (9 to 11):

Jake is a 14-year-old boy who just came back from traveling abroad with his parents on a tropical vacation. At the end of the vacation, he started having severe stomach cramps and lots of ‘very smelly’ diarrhea.

Patient Information:

• occasional blood in the stool
• pallor
• fatigue
• lips are parched
• diarrhea feels “hot” coming out
• feels very unwell
• nauseous
• achy
• forehead is hot
• Pulse: Rapid (Shuo) and Slippery (Hua)
• Tongue: red with a thick, yellow greasy coat

Question 10: Please choose four symptoms that are your red flags for referral for this biomedical impression. (Select 4)

CASE 5

Use the following information to answer questions (9 to 11):

Jake is a 14-year-old boy who just came back from traveling abroad with his parents on a tropical vacation. At the end of the vacation, he started having severe stomach cramps and lots of ‘very smelly’ diarrhea.

Patient Information:

• occasional blood in the stool
• pallor
• fatigue
• lips are parched
• diarrhea feels “hot” coming out
• feels very unwell
• nauseous
• achy
• forehead is hot
• Pulse: Rapid (Shuo) and Slippery (Hua)
• Tongue: red with a thick, yellow greasy coat

Question 11: This illness could cause a Liver abscess if not treated in time (True or False)

CASE 6

Use the following information to answer questions (12 to 14):

A new mom brings her 3-week-old baby in to see you and tells you that the Western medical treatments didn’t work for her son who has bright yellow skin and sclera.

Patient Information:

• baby has very warm body temperature since birth
• he is very irritable
• often crying
• will not eat much
• abdomen appears distended
• lips are dry
• very few bowel movements and cries when he does go
• urine is quite dark

Question 12: What is the name of his TCM Illness?

CASE 6

Use the following information to answer questions (12 to 14):

A new mom brings her 3-week-old baby in to see you and tells you that the Western medical treatments didn’t work for her son who has bright yellow skin and sclera.

Patient Information:

• baby has very warm body temperature since birth
• he is very irritable
• often crying
• will not eat much
• abdomen appears distended
• lips are dry
• very few bowel movements and cries when he does go
• urine is quite dark

Question 13: What is the TCM syndrome differentiation?

CASE 6

Use the following information to answer questions (12 to 14):

A new mom brings her 3-week-old baby in to see you and tells you that the Western medical treatments didn’t work for her son who has bright yellow skin and sclera.

Patient Information:

• baby has very warm body temperature since birth
• he is very irritable
• often crying
• will not eat much
• abdomen appears distended
• lips are dry
• very few bowel movements and cries when he does go
• urine is quite dark

Question 14: What is the treatment principle?

CASE 7

Use the following information to answer questions (15 to 17):

A 42-year-old female comes to your clinic complaining of massive bruising all over her body. She tells you that she often does not remember falling or even hitting the parts that are bruised and she cannot figure it out.

Patient Information:

• cuts herself shaving recently bled for an hour
• upon palpation, you note a mild splenomegaly
• sallow in complexion
• purple bruising on at least 7 parts of her body
• platelet count is quite low

Question 15: What is the name of her TCM Illness?

CASE 7

Use the following information to answer questions (15 to 17):

A 42-year-old female comes to your clinic complaining of massive bruising all over her body. She tells you that she often does not remember falling or even hitting the parts that are bruised and she cannot figure it out.

Patient Information:

• cuts herself shaving recently bled for an hour
• upon palpation, you note a mild splenomegaly
• sallow in complexion
• purple bruising on at least 7 parts of her body
• platelet count is quite low

Question 16: What is the most likely biomedical impression for this patient?

CASE 7

Use the following information to answer questions (15 to 17):

A 42-year-old female comes to your clinic complaining of massive bruising all over her body. She tells you that she often does not remember falling or even hitting the parts that are bruised and she cannot figure it out.

Patient Information:

• cuts herself shaving recently bled for an hour
• upon palpation, you note a mild splenomegaly
• sallow in complexion
• purple bruising on at least 7 parts of her body
• platelet count is quite low

Question 17: What is the possible fatal Western complication of this condition should it become severe?

CASE 8

Use the following information to answer questions (18 to 21):

A 23-year-old woman comes to your clinic complaining that her ‘breasts get lumpy’ before her period.

Patient Information:

• breasts become very swollen before period
• severe PMS
• no temperature change to the breast
• no nipple discharge
• doctor says there are 3 moveable nodules with undefined borders
• nodules are not hard and don’t feel adhered to the tissues

Question 18: What is her TCM Illness?

CASE 8

Use the following information to answer questions (18 to 21):

A 23-year-old woman comes to your clinic complaining that her ‘breasts get lumpy’ before her period.

Patient Information:

• breasts become very swollen before period
• severe PMS
• no temperature change to the breast
• no nipple discharge
• doctor says there are 3 moveable nodules with undefined borders
• nodules are not hard and don’t feel adhered to the tissues

Question 19: What is the most likely syndrome differentiation?

CASE 8

Use the following information to answer questions (18 to 21):

A 23-year-old woman comes to your clinic complaining that her ‘breasts get lumpy’ before her period.

Patient Information:

• breasts become very swollen before period
• severe PMS
• no temperature change to the breast
• no nipple discharge
• doctor says there are 3 moveable nodules with undefined borders
• nodules are not hard and don’t feel adhered to the tissues

Question 20: Do you think she has to worry about breast cancer?

CASE 8

Use the following information to answer questions (18 to 21):

A 23-year-old woman comes to your clinic complaining that her ‘breasts get lumpy’ before her period.

Patient Information:

• breasts become very swollen before period
• severe PMS
• no temperature change to the breast
• no nipple discharge
• doctor says there are 3 moveable nodules with undefined borders
• nodules are not hard and don’t feel adhered to the tissues

Question 21: What do you think her Western diagnosis would be?

CASE 9

Use the following information to answer questions (22 to 25):

Adam has been suffering from sciatica for the past 5 years. It has always been manageable, but during the last month has worsened tremendously.

Patient Information:

• pain radiates along the lateral and posterior aspect of his hip and thigh, reaching as far down as the lateral malleolus
• limping for the last month
• leg feels heavy
• interrupted sleep as the pain becomes more severe at night
• heating pad applied to the affected area lessens his discomfort
• Tongue: thin white coat
• Pulse: Tight (Jin)

Question 22: Your current diagnosis would be:

CASE 9

Use the following information to answer questions (22 to 25):

Adam has been suffering from sciatica for the past 5 years. It has always been manageable, but during the last month has worsened tremendously.

Patient Information:

• pain radiates along the lateral and posterior aspect of his hip and thigh, reaching as far down as the lateral malleolus
• limping for the last month
• leg feels heavy
• interrupted sleep as the pain becomes more severe at night
• heating pad applied to the affected area lessens his discomfort
• Tongue: thin white coat
• Pulse: Tight (Jin)

Question 23: Which meridians reflect most accurately the distribution of symptoms?

CASE 9

Use the following information to answer questions (22 to 25):

Adam has been suffering from sciatica for the past 5 years. It has always been manageable, but during the last month has worsened tremendously.

Patient Information:

• pain radiates along the lateral and posterior aspect of his hip and thigh, reaching as far down as the lateral malleolus
• limping for the last month
• leg feels heavy
• interrupted sleep as the pain becomes more severe at night
• heating pad applied to the affected area lessens his discomfort
• Tongue: thin white coat
• Pulse: Tight (Jin)

Question 24: Which extra meridian best reflects the distribution of symptoms?

CASE 9

Use the following information to answer questions (22 to 25):

Adam has been suffering from sciatica for the past 5 years. It has always been manageable, but during the last month has worsened tremendously.

Patient Information:

• pain radiates along the lateral and posterior aspect of his hip and thigh, reaching as far down as the lateral malleolus
• limping for the last month
• leg feels heavy
• interrupted sleep as the pain becomes more severe at night
• heating pad applied to the affected area lessens his discomfort
• Tongue: thin white coat
• Pulse: Tight (Jin)

Question 25: Which point combination would you use to treat Adam?

CASE 10 

Use the following information to answer questions (26 to 28):

A 9-year-old boy is suffering from enuresis at night.

Patient Information:

• he is emaciated
• dark circles under his eyes
• displays no interest in playing with the toys you present him with
• complexion is pale
• his mother mentions that it is extremely tough to get him to eat anything
• he mostly just sits and watches TV, while his siblings are all playing outside
• Tongue: pale with a thin white coating
• Pulse: Deep (Chen) and Thready (Xi)

Question 26: What is the best TCM diagnosis?

CASE 10 

Use the following information to answer questions (26 to 28):

A 9-year-old boy is suffering from enuresis at night.

Patient Information:

• he is emaciated
• dark circles under his eyes
• displays no interest in playing with the toys you present him with
• complexion is pale
• his mother mentions that it is extremely tough to get him to eat anything
• he mostly just sits and watches TV, while his siblings are all playing outside
• Tongue: pale with a thin white coating
• Pulse: Deep (Chen) and Thready (Xi)

Question 27: The most accurate treatment principle is:

CASE 10 

Use the following information to answer questions (26 to 28):

A 9-year-old boy is suffering from enuresis at night.

Patient Information:

• he is emaciated
• dark circles under his eyes
• displays no interest in playing with the toys you present him with
• complexion is pale
• his mother mentions that it is extremely tough to get him to eat anything
• he mostly just sits and watches TV, while his siblings are all playing outside
• Tongue: pale with a thin white coating
• Pulse: Deep (Chen) and Thready (Xi)

Question 28: Which of the following is the best point combinations?

CASE 11

Use the following information to answer questions (29 to 30):

Joan just turned 72 and has suffered from Rheumatoid Arthritis for the past 15 years.

Patient Information:

• her Medical Doctor has prescribed anti-inflammatory drugs for the last decade
• mobility issues
• knees particularly inflamed and have become deformed
• knees become more painful in cold, rainy weather
• upon palpation you find small, soft nodules on the medial aspect of both knees
• knee pain is worse upon bending the knees
• painful when the area around ST 35 is palpated on both sides
• Joan is strongly considering moving to Arizona – a much warmer and drier climate as she cannot be around the cold anymore
• hands have atrophied
• trouble with small motor movements
• pale white complexion
• Tongue: pale, with toothmarks on the edges with a white coat
• Pulse: Slow (Chi), Weak (Ruo), Deep (Chen) in both proximal positions

Question 29: Which TCM diagnosis is most likely present?

CASE 11

Use the following information to answer questions (29 to 30):

Joan just turned 72 and has suffered from Rheumatoid Arthritis for the past 15 years.

Patient Information:

• her Medical Doctor has prescribed anti-inflammatory drugs for the last decade
• mobility issues
• knees particularly inflamed and have become deformed
• knees become more painful in cold, rainy weather
• upon palpation you find small, soft nodules on the medial aspect of both knees
• knee pain is worse upon bending the knees
• painful when the area around ST 35 is palpated on both sides
• Joan is strongly considering moving to Arizona – a much warmer and drier climate as she cannot be around the cold anymore
• hands have atrophied
• trouble with small motor movements
• pale white complexion
• Tongue: pale, with toothmarks on the edges with a white coat
• Pulse: Slow (Chi), Weak (Ruo), Deep (Chen) in both proximal positions

Question 30: Which acupuncture point combination is best suited for Joan?

CASE 12

Use the following information to answer questions (31 to 33):

Jeremy, mid-twenties, has been suffering from sleep related problems for the past year.

Patient Information:

• difficulty in falling asleep
• disturbing dreams
• palpitations
• poor memory
• dizziness
• blurry vision
• fatigue
• lack of appetite
• sallow complexion
• Pulse: Thready (Xi), Weak (Ruo)

Question 31: You would suspect that Jeremy’s tongue is most likely:

CASE 12

Use the following information to answer questions (31 to 33):

Jeremy, mid-twenties, has been suffering from sleep related problems for the past year.

Patient Information:

• difficulty in falling asleep
• disturbing dreams
• palpitations
• poor memory
• dizziness
• blurry vision
• fatigue
• lack of appetite
• sallow complexion
• Pulse: Thready (Xi), Weak (Ruo)

Question 32: What is the best TCM diagnosis?

CASE 12

Use the following information to answer questions (31 to 33):

Jeremy, mid-twenties, has been suffering from sleep related problems for the past year.

Patient Information:

• difficulty in falling asleep
• disturbing dreams
• palpitations
• poor memory
• dizziness
• blurry vision
• fatigue
• lack of appetite
• sallow complexion
• Pulse: Thready (Xi), Weak (Ruo)

Question 33: Which acupuncture point combination might work the best for Jeremy?

CASE 13

Use the following information to answer questions (34 to 35):

Mark presents with epigastric pain, thirst with a desire to drink cold liquids, sour/acid regurgitation, a voracious appetite, red tongue with a thick yellow coating, and a Full (Hong) pulse.

Question 34: What additional symptom would you suspect Mark to have?

CASE 13

Use the following information to answer questions (34 to 35):

Mark presents with epigastric pain, thirst with a desire to drink cold liquids, sour/acid regurgitation, a voracious appetite, red tongue with a thick yellow coating, and a Full (Hong) pulse.

Question 35: What TCM pattern is Mark presenting with?

CASE 14

Use the following information to answer questions (36 to 37):

Ellen has been experiencing chronic leukorrhea for 4 years.

Patient Information:

• discharge is generally clear and odorless
• long history of skin infections
• large patches of lesions on her arms which are dry, light pink and quite scaly
• she tells you that skin in the area around her vulva and perineum is itchy and inflamed
• a few months ago, she had athlete’s foot so severely that the lesions extended all the way to her knees
• heavy periods with dark clotted blood and bad cramps
• heating pad usually helps a bit
• insomnia
• overweight
• lost her left kidney 5 years ago due to a car accident
• Tongue: pale with toothmarks on the edges, light white coating
• Pulse: Slow (Chi) and Deficient (Xu)

Question 36: The root cause of Ellen’s problems is:

CASE 14

Use the following information to answer questions (36 to 37):

Ellen has been experiencing chronic leukorrhea for 4 years.

Patient Information:

• discharge is generally clear and odorless
• long history of skin infections
• large patches of lesions on her arms which are dry, light pink and quite scaly
• she tells you that skin in the area around her vulva and perineum is itchy and inflamed
• a few months ago, she had athlete’s foot so severely that the lesions extended all the way to her knees
• heavy periods with dark clotted blood and bad cramps
• heating pad usually helps a bit
• insomnia
• overweight
• lost her left kidney 5 years ago due to a car accident
• Tongue: pale with toothmarks on the edges, light white coating
• Pulse: Slow (Chi) and Deficient (Xu)

Question 37: What is the best acupuncture point combination for Ellen’s condition?

CASE 15

Use the following information to answer questions (38 to 40):

A patient complains that, since yesterday, he has suffered from severe bouts of coughing of a choking character.

Patient Information:

• coughing is immediately followed by wheezing
• distending sensation in the chest, which radiates upwards from the Lung
• cough causes chest and hypochondriac pain
• cough becomes more severe when lying down
• cough accompanied by thick phlegm, sometimes containing a small quantity of small blood clots
• thirsty
• likes to drink a lot of fluid
• general bitter taste in his mouth
• poor appetite
• general lassitude
• yellow urine and constipation for the past 2 days
• hot feeling on his skin
• Tongue: red body, yellow coat
• Pulse: Forceful (Youli), Full (Hong) with a very strong right distal region

Question 38: What is the most accurate TCM diagnosis?

CASE 15

Use the following information to answer questions (38 to 40):

A patient complains that, since yesterday, he has suffered from severe bouts of coughing of a choking character.

Patient Information:

• coughing is immediately followed by wheezing
• distending sensation in the chest, which radiates upwards from the Lung
• cough causes chest and hypochondriac pain
• cough becomes more severe when lying down
• cough accompanied by thick phlegm, sometimes containing a small quantity of small blood clots
• thirsty
• likes to drink a lot of fluid
• general bitter taste in his mouth
• poor appetite
• general lassitude
• yellow urine and constipation for the past 2 days
• hot feeling on his skin
• Tongue: red body, yellow coat
• Pulse: Forceful (Youli), Full (Hong) with a very strong right distal region

Question 39: What which treatment principle is the best for this patient?

CASE 15

Use the following information to answer questions (38 to 40):

A patient complains that, since yesterday, he has suffered from severe bouts of coughing of a choking character.

Patient Information:

• coughing is immediately followed by wheezing
• distending sensation in the chest, which radiates upwards from the Lung
• cough causes chest and hypochondriac pain
• cough becomes more severe when lying down
• cough accompanied by thick phlegm, sometimes containing a small quantity of small blood clots
• thirsty
• likes to drink a lot of fluid
• general bitter taste in his mouth
• poor appetite
• general lassitude
• yellow urine and constipation for the past 2 days
• hot feeling on his skin
• Tongue: red body, yellow coat
• Pulse: Forceful (Youli), Full (Hong) with a very strong right distal region

Question 40: Which set of acupuncture points will be the most helpful?