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SAMPLE CASE STUDY BASED ON ACTUAL PATIENT
International Academy of Medical Acupuncture Case Studies
Case Number: 14
Patient Initials: JSW
Initial Date of Patient Consult/Treatment: January 13
th
, 2004
Patient Age: 43 Gender: Female Occupation: Office Manager
Subjective Patient Complaints: Adult onset asthma- Dyspnea, cough and occasional
wheezing symptoms upon increased physical exertion/ exercise or “stress” situations
Onset: Three years ago insidiously, although after thorough questioning of the patient she
revealed that she had lost a beloved pet and experienced much grief.
What palliates/provokes the symptoms? Provoked by exercise, emotional/physical Stress,
cigarette smoke, mold, and also worse with seasonal respiratory allergies. Acute dyspnea and
asthma symptoms temporarily eased with prescription bronchial inhaler medication.
Quality of symptoms: Bronchial spasm creating difficult expiration; a sensation of tightness
in the chest, occasional wheezing symptoms. This patient states that on a scale of 1-10, where
10 is the best, she rates her symptoms as a three, due to the amount of interruption and
disturbance to her normal daily routine.
Is there any radiation of symptoms? The dyspnea, wheezing and cough often causes neck
and upper back soreness and stiffness, “tightness” sensation in chest, and occasional sore throat
from the forceful coughing.
Describe the site of symptomatology: Bronchial, Lung, Chest/ Thoracic region
Time of day/ duration of symptoms: Daily episodes of dyspnea. Symptoms often worse
@3-5 AM causing patient to awake coughing. Patient reports having to use medication
(bronchial inhaler) at least 3-4 times a day typically associated with the above mentioned
stressors.
Prior contributory health history: 1) Seasonal upper respiratory allergies, primarily Spring
and Fall 2) Occasional episodes of mild eczema (dermatitis) over the last few years on hands
and forearms in times of extreme grief/stress 3) Occasional loose stools when under stress
4)Reports a history of being healthy, aside from this recent asthma problem; and athletic,
involved in recreational sports. She enjoys caring for and riding her two horses but now finds
difficulty exercising aerobically due to the dyspnea.
Characteristics of symptoms based upon Five Element Theory: a) Emotion of grief
associated with the Lung meridian and skin conditions, as in this patients eczema. b) Patient’s
stress often causes loose stool, indicative of the coupled meridian association of Lung/ Large
Intestine. C) The white pallored skin hue is also associated with the metal element (lung and
large intestine).
Objective Findings:
Diagnostic Test Results: