A Step-By-Step Guide To Breaking Down Any TCM Case Study Gillian Marsollier, R.Ac.

Introduction This is the course that I wish my instructors taught me. Since I have been using the techniques you are about to learn, I have been able to comprehend deeply any complex TCM case that walks through my clinic doors. There are 2 main scenarios that you might find yourself in as you begin this course. 1) You have a big board exam coming up that is going to be your ticket into your dream profession. BUT, you know that there are a lot of difficult and complex case studies to answer correctly before you get your license. You are probably wondering – what and how should I study? How do I know if I am breaking them down correctly? Or, what do I do if there is a case on the exam that is an entire page? How am I going to get to the right answer in the maze of symptoms before me? OR… 2) You’ve are starting your clinical internships, OR finished your TCM college education, and you are excited to start treating real, live patients. Ahhhh, you have finally arrived. You start marketing, or start your course, and see that your very first patient has booked in for Monday morning at 9am. Excited, you nervously await this milestone moment. Monday morning, a 76-year-old woman ambles in. Your first sweat sheens off your back. You take her in for her initial intake and you have no idea where to start. You ask how you can help her with and her history becomes vast and complicated. By the end of the first hour you have 3 pages of notes with random symptoms everywhere. You don’t even know why she is coming anymore and are thoroughly confused. You let her know that the first treatment is intake only (you just decided this as you eye the time and have no idea what her diagnosis is) and ask her to come back next week for her first acupuncture treatment. She thanks you graciously and leaves.

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You sit back and have a silent heart attack while your mitt of sweaty notes sag in mockery of you and your last 1.5 hours of serious-faced confusion. Headlines flash through your head, ‘Charlatan Acupuncturist Unmasked!’ “What. The. HECK. Do I Do Now? Did I learn ANYTHING in college?” My name is Gillian Marsollier and I have been in the acupuncture field for 18 years. I have taught intensively for 10 and also tutor students via Skype in distant places. I have been the program director for burgeoning colleges and have created almost the entire curriculum for an entire acupuncture program. I teach workshops to prepare students for their board exams, and with excellent results. In the meantime I have always maintained a very busy practice that almost always has a waitlist. I would say that overall most students get a good base education at their college. They tend to use great textbooks, get through their exams and can decently debate TCM ideas and notions with their peers. But, I have noticed a glaring deficiency. All these wonderful students with all of this wonderful knowledge, but very few of them know how to properly break down a case. They get a slightly-to-decently complex case walking through their doors and they have no idea where to begin and no idea how to set up a treatment plan. The reason for this is simple. It is rarely taught. Most students learn all about their theories and foundations, but are not taught how to put it together when you are actually in human-to-human contact, or are faced with a very difficult case on paper. How do I know where to start? What is their primary diagnosis? Secondary? How did they get from there to here? (in addition – patients love to understand how they got their also!) What is my treatment principle?

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How the heck do I choose the right points for their problems? And…one of the most important questions – I’ve given them a treatment –NOW WHAT? This course was created to help you get through any TCM Case Study Efficiently and Effectively. This is not a course to teach you TCM, that was up to your college, and is up to you to review! That being said, I am going to have you go over some key areas. COURSE OUTLINE • Foundations • Cardinal Symptoms Definition And Practice • Ben/Biao • Case Breakdown Definitions • Unique Way To Find Pathogenesis • How To Use The Template • Audio Intake Of Patient • Case Breakdown Lessons + Demos • Case Breakdown Practice • Case Study Exam • Additional Video For Pan-Canadian Examination Students STOP – If you are a student, please complete all of the following sections before going to ‘Breaking Down a Case’. If you are a practitioner, feel free to watch all sections first, try some cases out, and then see where you need to focus your foundational basics after. That being said, it can’t hurt to go through it all again if you feel the need.

FOUNDATIONS, FOUNDATIONS, FOUNDATIONS Gillian Marsollier R.Ac.

Please repeat the title of this chapter over and over and over. If you are stuck on a case…repeat those 3 words. If you feel a case is too complex…repeat those 3 words. I am going towards telling you the best format to break down cases, but first you must know that it all truly comes back to your knowing your TCM foundations inside and out. In order to break down your cases efficiently and effectively, you NEED to understand the absolute fundamentals of: • Yin/Yang, 8 Principles • Qi, Blood, Body Fluids, Essence • 6 EPFs/7 Emotions • Zang Fu Organ Functions, Etiology, Zang Fu Syndrome Differentiations • Ben/Biao (root/branch) Now wait… I just heard your thoughts: “yah, yah, I know my foundations, this book isn’t telling me anything I don’t know.” No. No, that’s not true. I’m telling you, you don’t know them as well as you think you do. I promise you that by the time you do the assignments in the next few chapters, and start playing with case breakdown, you will SEE what part of your foundations need more study. This is a great thing, because then you will know with certainty which areas to focus your studies. The 4 Pillars Even though I am focusing on these main foundations, do know that is extremely important to also re-read the 4 Pillars (Observation, Auscultation/Olfaction, Palpation, and Interrogation). For examples of what I mean: when reading a case, you should immediately know what it means if a patient has: -Yellow around their mouth (SP/ST); -Diarrhea with no smell (SP/ST xu); -Loud breathing (excess pattern); -Headache that is better with rest (qi deficiency);

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-Sweating only on the hands LU qi deficiency); -Pain with the quality of heaviness (damp/phlegm) And the list goes on… You can refer to your notes from your foundations class, or to your preferred foundations textbook. But Really, Know Everything Ideally you know all of your TCM basics for your best exam results and best clinical results. I will just be taking you through the main parts in this course, and it is up to you to do a thorough study. You should also be well-aware of the following: -Channel Pathology/Jing Luo (know their full trajectories in order to recognize channel involvement – this includes all channels – main, luo, divergent, sinew), Bi Pain -6 Stages, 4 Levels, San Jiao Syndrome Differentiations -Extraordinary Vessels -Zang Fu Relationships Between the Organs – especially the YIN ORGANS. This is very, very helpful. Ok, they are so important, that I am going to add

them in here (from a wonderful site called Sacred Lotus, very well said): Heart and Lungs • Heart governs Blood, Lungs govern Qi: relationship is that of Qi and Blood. • Qi and Blood are interdependent. Blood nourishes Qi but Qi pushes the Blood. • Heart moves the Blood but relies on Lung Qi to assist. • Lungs produce Ying (and Wei) Qi. Ying Qi flows with the Blood in the Vessels. • Heart and Lung connect via the Zong Qi (Chi of the Chest) • Deficient Lung Qi can lead to stagnation of Qi in the Heart and this can lead to

stagnation of Blood of the Heart, with symptoms such as palpitations, chest pain, blue lips.

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• Excessive Heart Fire can dry up Lung fluids and cause dry cough, dry nose and thirst.

• In practice, Heart and Lung Qi are often deficient at the same time because of their close relationship.

• Sadness often depletes both Lung and Heart Qi. Heart and Liver • The heart and the Liver are related via Blood. • Heart governs Blood, Liver stores Blood and regulates its volume. These two

activities must be coordinated and harmonized. If Heart Blood is deficient, this may disrupt Liver's ability to regulate Blood (dizziness, excessive dreaming).

• Deficient Liver Blood can cause Deficient Heart Blood (palpitations and insomnia).

• Heart stores Shen and Liver rules smooth flowing of the emotions. • Shen and emotions mutually support each other. Weak Heart and Shen may

lead to depression and anxiety. Or, when Liver Qi stagnates, this constrains emotions and can weaken the Shen.

Heart and Kidneys • Mutual assistance of Fire and Water. • Heart belongs to Fire element and is in Upper Burner. (Fire is Yang and

corresponds to movement). • Kidneys belong to Water element and are in Lower Burner. (Water is Yin and

corresponds to stillness). • Heart & Kidney must be in balance as they represent two fundamental polarities

of Yang and Yin (Fire & Water). • Heart Yang descends to warm Kidney Yin while Kidney Yin ascends to nourish

Heart Yang. This constant interchange is referred to as "mutual support of Fire and Water".

• Kidney Yang Deficient: Kidneys cannot transform fluids; these can overflow upward to Heart.

• Kidney Yin Deficient: Yin cannot rise to nourish Heart Yin. This can cause overactive Heart Fire (mental restlessness, insomnia, agitation, etc.)

• Both these situations represent loss of communication between Heart and Kidney.

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• Heart and Kidneys are Common Root of Shen and Essence (Jing). The Heart houses She, while the Kidneys store Jing.

• Shen and Jing have common root. Jing is fundamental substance from which Shen is derived, in other words, Shen is external manifestation of Jing.

• Prenatal Jing is the foundation of the Shen, Postnatal Jing provides nourishment for the Shen.

• Normal mental activity needs good supply of Jing. • Weak Jing: Shen will be weakened and person will lack vitality, willpower, self

confidence. • When Shen is disturbed by emotional problems, Jing will not be directed by the

Shen and the person will feel tired and lack motivation. Liver and Lungs • Reflects the relationship of Qi and Blood. • Lungs govern Qi, and the Liver regulates and stores the Blood. • They rely on each other in that the Liver relies on Lung Qi to regulate Blood, and

the Lungs rely on Liver Qi to smoothly move Qi. • Deficient Lung Qi can affect Liver's smooth movement of Qi (fatigue, depression,

cough and hypochondriac pain). • Liver Qi can stagnate in the chest and interfere with the Lung's function of

descending (cough, dyspnea, asthma). • Stagnation of Liver Qi can cause Liver Fire to rise and injure Lung Yin

(Hypochondriac pain, coughing blood, pain on breathing). Liver and Spleen • When healthy, Liver Qi aids Spleen in digestion, and ensures smooth flow of bile

to aid digestion. • By ensuring smooth flow of Qi in all directions of the body, Liver ensures that

Spleen Qi flows upwards in its right direction. • Stagnant Liver Qi disrupts Spleen ability to transform and transport food and

fluids and to "raise the pure". (abdominal distension, hypochondriac pain, diarrhea).

Liver and Kidneys • Based on mutual exchange between Blood and Jing.

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• Kidney Jing contributes to the making of Blood. (Jing produces bone marrow which is connected with manufacture of Blood in the body).

• "Liver and Kidneys have a common origin". • "Essence and Blood have a common source". • Kidney Yin nourishes Liver Yin (including Liver Blood). • Deficient Kidney Jing may lead to Blood becoming Deficient (dizziness, blurred

vision, tinnitus). • Kidney Yin fails to nourish Liver Yin, causing hyperactivity of Liver Yang (blurred

vision, tinnitus, headaches, irritability, dizziness. Spleen and Lungs • Mutually assist each other. • Spleen extracts Food Qi and sends it up to the Lungs where it combines with air

to form Zong Qi. • Spleen relies on Lung descending function to assist in the transformation and

transportation of food (diaphragm movement helps Middle burner - "pumping" action).

• Lung descending function also assists Spleen in the transformation of Body Fluids. Lung Qi weak, descending function impaired, Spleen cannot transform and transport the fluids, causing edema.

• Deficient Spleen Qi: Food Qi deficient and production of Qi impaired (especially of Lung Qi: tiredness, weak limbs, breathlessness, weak voice) (Earth not producing Metal).

• Spleen Deficiency: fluids not transformed but accumulate to form Phlegm, which settles in Lungs and impairs Lung function. "The Spleen forms Phlegm, the Lungs store it."

Spleen and Kidneys • Relationship is one of mutual nourishment. • Spleen: Root of Post-Heaven Qi (Foundation of Postnatal Existence) • Kidneys: Root of Pre-Heaven Qi (Foundation of Prenatal Existence) • The Postnatal Essence (Postnatal Jing) is formed from the food we eat and the

air we breathe. The Spleen therefore plays the most important role in the formation of Postnatal Essence.

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• The Postnatal Essence is stored in the Kidneys together with the Prenatal Essence. Where Spleen Qi is weak, Postnatal Essence will not be produced as effectively, and the Kidney will have less Postnatal Essence to store.

• Prenatal Essence assists in the production of Qi via its active aspect (Original Qi): the Original Qi provides the necessary energy for the transformation and transportation of the substances and formation of Qi: this affects the Spleen's function.

• Spleen and Kidneys support one another regarding transformation/transportation of Body Fluids.

• Where Spleen Qi is weak, and Body Fluids are not able to be transformed and transported, these accumulate to form Dampness, which can interfere with the Kidney's function regarding fluid metabolism (which then makes the Dampness worse).

• Where Kidney Yang is Deficient, there is not enough heat for the Spleen to transform Fluids: this can cause Dampness or edema, chilliness and diarrhea.

Lungs and Kidneys • Important relationship with regard to Qi and Fluids • Qi • Lungs send Qi and Fluids down to the Kidneys. Kidneys hold down the Qi and

evaporate some of the Fluids, then send fluid vapor back to the Lungs to moisten them and the Lung then sends Fluids to moisten the skin.

• Lungs send Qi down the Kidney and Kidneys hold down the Qi. Therefore they have an important communication regarding respiration

• Communication regarding Zong Qi and Original Qi. Zong Qi (in the chest) flows down to connect with the Original Qi from which it is nourished. Original Qi flows up to the chest to assist with the production of Qi and Blood in the Upper Burner.

• The Lung function of governing Qi and respiration depends on the Kidney function of receiving Qi.

• Where Kidney energy is weak: impaired reception of Qi. Kidneys fail to hold Qi down and Qi flows back up to the chest ("rebels") and obstructs the Lung's descending function. Result is asthma, cough and dyspnea (unable to inhale deeply).

• Fluids

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• Lungs control Water passages and send Fluids down to the Kidneys. Kidneys evaporate some fluids and send them back up to the Lungs to keep Lungs moist. "Kidneys govern Water and the Lungs are the upper origin of Water."

• Deficient Lung Qi: Lung cannot send fluids downwards and Lung cannot communicate with Kidneys and Bladder (edema, especially of upper body).

• Deficient Kidney Yang: Kidneys cannot transform and excrete Fluids in the Lower Burner. These Fluids then accumulate to form Dampness or edema (especially of lower body). Because of the close relationship of Lungs and Kidneys regarding fluid metabolism, this accumulation of Fluids can eventually affect the Lung and impair Lung's descending and dispersing function.

• Deficient Kidney Yin: leads to deficiency to Fluids in the Lower Burner. Fluids fail to rise to moisten the Lungs, causing Deficiency of Lung Yin (dry throat at night, dry cough, night sweats and feeling of heat in the palms and soles of the feet).

• Deficient Lung Yin (can arise from smoking, or after a long febrile disease involving the Lungs). This implies Deficient Fluids in the Lungs, inability of Lungs to send Fluids to Kidneys, which then results in Deficient Kidney Yin. (Smokers usually end up with depleted Kidney Yin as a result of this mechanism).

Spleen and Heart • Interrelated via the Blood. • Spleen provides Food Qi for the formation of Blood. • Deficient Spleen Qi can lead to Deficient Blood, which can cause Heart Blood to

be Deficient (resulting in palpitations, dizziness, poor memory, insomnia). STOP - If you are studying for your big exam right now, know that you need to know EVERYTHING your examination guidelines tell you to know. Don’t skip anything as that could be the year that a couple of cases are heavy in that area! Again, this course is to show you how to break down cases, not teach you all of your TCM (that is your job at this point!)

Cardinal Symptoms Gillian Marsollier R.Ac.

Just before we start this section, let’s define what I call CARDINAL SYMPTOMS: Cardinal symptoms are the KEY symptoms that make one pattern/imbalance stand out from the rest. Here is an example: • LV yang rising, LV heat, LV fire These 3 are often confused with each other, but if we look at their cardinal symptoms, we will see how to differentiate them from each other in a case. In an exam, you need to be efficient with this process, and in clinic, these words need to stand out for you immediately. Ok, let’s cross compare (do realize that a bit of overlap happens all the time, it is the series of symptoms together that is key – it may not be every single cardinal symptom, but it will at least be a couple to a few of them): LV yang rising - dizziness WITH STRESS or OVERWORK, mild red face, night sweats, malar flush, frequent waking/restless insomnia, temper, high pitch tinnitus, temporal/vertex or pounding/pulsating headache, t: red sides, p: wiry – notice how LV yang rising doesn’t have much for digestive signs and has yin deficiency at it’s root. LV heat - dizziness with STRESS or YANG FOODS/DRINK, constipation, dark yellow, scanty urine, red face, red eyes, big temper, distend hypochondrium, t: red with dry, yellow coat, p: wiry, rapid, excess – note the bigger heat signs and no yin deficiency here. LV fire – red, swollen, painful eyes, epistaxis, hematemesis, hemoptysis, burning hypochondrium, rage/huge temper, red face, dizziness, constipation, dark yellow urine, t: red with thick, dry, yellow coat, p: full, wiry, rapid – note the bleeding and huge heat (fire) signs here.

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I hope you can see how to do your cardinal symptoms from these examples, because we are about to do A LOT more!

Yin/Yang, 8 Principles Gillian Marsollier, R.Ac.

Yin/Yang

The beginning of this course may seem too simple, but trust me, it isn’t. IT IS THE KEY TO CASE STUDIES! It isn’t uncommon to see this being the problem area for many students. I can honestly say, that when you read any complex case, you can say to yourself, “Is this an issue with yin, or yang?” That will be a powerful guidepost to finding the correct diagnoses. It may sound too simple, but since yin/yang is at the root of all imbalances, it is actually the most effective start. Let’s review yin/yang and then look at examples of how to use it with cases: i) Opposition - yin/yang are opposite in nature ii) Interdependence - yin/yang cannot exist without the other iii) Mutual Consumption - yin/yang consume each other when in excess iv) Inter-Transformation - yin/yang can transform into the other at extremes (only at certain stage of development). This is often the case with terminal, severe illnesses. What we deal most with in clinic is an imbalance of #3 – the law of Mutual Consumption. Most patients are coming to see you because they have had a condition of one of Yin/Yang or the 8 Principles for too long. They may have had EXCESS HEAT (yang) for many years, and now the yin is consumed (yin deficiency). Or, perhaps they have had EXCESS DAMP (yin) for a number of years, and now the yang, after being blocked for long-term, becomes consumed (yang deficiency). Yin/Yang Correspondence Charts – A quick review These charts are incredibly important. For example, if you are reading a case with a patient who has REDNESS on his BACK, your brain can immediately start considering YANG as a main culprit. Or perhaps it is a patient who is COLD and PALE; obviously YIN may be the issue (careful not to get YIN and

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YIN DEFICIENCY confused. YIN is this chart here; YIN DEFICIENCY is an empty heat state). YANG YIN Universal Day Night Spring/Summer Autumn/Winter/Cloudy Upper Lower Exterior Interior Hot/fire Cold/Water Light/Sun Dark/Moon Action/Function/Process/

Movement/Strong/ Assertion

Potential Energy/Recessive/ Nurturance

Bodily Surfaces Interior Spine/Back Chest/Abdomen Male Female Clear/Clean body fluid Turbid/Cloudy/Unclean

body fluids Energy (qi) Blood Wei Qi Ying (nourishing) Qi In Disease Acute/Virulent Chronic/Inactive Powerful/Flourishing Weak/Decaying Fever/Hot to touch Patient feels cold/Cold

to touch/Hypothermal Dry Moist Advancing Retiring/Contracting Hasty Lingering Constipation Diarrhea Dark, yellow, scanty

urine Profuse, clear urination

Redness Pallor Aggressive Meek/Weak

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Feel Free to Add More Another example is if a patient comes in for infertility. He knows that he has a proper amount of sperm, but his doctor tells him he has low MOTILITY. Well, can you guess? Since motility is a function of YANG, and it is DEFICIENT, perhaps we have a YANG DEFICIENCY syndrome on our hands (of course, you will investigate a lot further, but this is your starting point). Any complex case should have your brain coming back to YIN/YANG to start. YIN/YANG IMBALANCES Especially for the visual learners out there, let’s look at all the imbalances of yin/yang

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This chart is incredibly important, as it will direct your treatments. Do you tonify yin, or just clear excess heat? You need to understand which is which so that you don’t deplete your patient, or aggravate their condition. Let’s start to use the idea of creating cardinal symptoms for each. I will do one for you, the rest you can fill out yourself in the blank template you’ll see under your ‘Resources’. We have 4 imbalances of yin/yang: yin excess, yin deficiency, yang excess, yang deficiency. I will show you the cardinal symptoms of yin deficiency before you start

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filling in your template. Yin Deficiency Cardinal Symptoms – Night sweats, restless sleep with frequent waking, restless mind, restless fatigue (patient feels tired but is fidgety and wired), malar flush, 5-centre heat, dry mouth with only desire for small sips, t: red without coat, p: thready, rapid. So these are your CARDINAL symptoms. There are more, but these are the ones that will make this pattern pop out of your case study. A Small Side-Note: Strict memorization of TCM is a mistake. It doesn’t allow one to be able to tackle any case. The key is to understand why things happen as they do. For example - there are many types of poor sleep, but we need to know that because nighttime is yin time, if it is weak, it will show up most then. Therefore, if the yin is too low to ground yang, the patient will have a FALSE YANG (as it is only due to deficient yin not grounding) constantly rising up to agitate the shen/mind. So, the patient wakes frequently with heat, restless mind and sweats. Take the time to go through each symptom, and be able to explain why it presents as it does.

8 Principles

The 8 principles are basic and dire concepts to grasp. You need to be able to tell excess pain from deficient pain (for example), cold signs from heat signs, interior from exterior, and yin from yang. Let’s do our first cardinal symptoms example together, and then you can go to the blank template worksheet under ‘Resources’ and fill in the rest. You can check your answers in your foundations text. Excess Cardinal Symptoms: Acute (usually), loudness (breathing, voice,

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movements), tends towards heat, irritable, constipation, pain worse with pressure, better with movement or with evacuation (bowels, vomiting, etc.), fullness/distention, painful or difficult urination, t: thick coat, p: full, strong STOP - Grab your templates and fill in the ‘Yin/Yang’ and ‘8 Principles’ sections now. When completed, come back to do the practice cases below. Remember: Cardinal Symptoms only please! Cases Now that you have finished your templates, please complete the following case noting only the YIN/YANG imbalances. I like to draw a small line from each symptom and off to the side denoting the imbalance. For example, Fatigue (draw a line) ------- deficiency. You will see this a lot in the videos later. Don’t attach any zang fu organs – keep it simple - (answer at the top of the next lecture): 1) Main Complaint: Insomnia History: Frequent insomnia for the past two years. It is not difficult to fall asleep initially, but he has many dreams and wakens easily, after which he finds it difficult to go back to sleep. The patient feels very restless and sometimes has a hot, feverish sensation with sweating when the restlessness becomes severe. In addition, he sometimes wakes up to find that he has been sweating during sleep. The patient has dizziness in the morning with a heavy sensation around the head, and high frequency, 'cicada-like' tinnitus. He also complains of severe general lassitude, and feels cold all the time, with cold extremities. He is very sensitive to temperature changes and has an aversion to heat and cold alike, being unable to adapt quickly. His appetite is poor and he has very bad digestion. He has a dry mouth, likes to drink small sips of water, and complains of urinary frequency, getting up 3-4 times a night to urinate. He has loose stools with undigested food in it about twice/day. He also

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complains of pain and coldness of the knee joints. His complexion is pale. Using 8 Principles only, please apply them to the following case (answer at the top of the next lecture): 2) Main Complaint: Insomnia History: One-year history of insomnia. The patient usually wakes between 3 and 4 AM and finds it difficult to fall back to sleep. He occasionally remembers his dreams. The patient feels that his level of mental energy during the day is poor, feels drowsy, and suffers from dizziness and poor memory. His food intake is less than average and he has abdominal distension after eating. He has general lassitude but is not restless and has no feelings of fever or cold. He is not thirsty. Urination and bowel movements are normal. Tongue: Pale body with a thin white coating Pulse: Thin

Qi, Blood, Body Fluids, Essence Gillian Marsollier, R.Ac.

Answers To Previous Lecture Case Questions – 1) BOTH YIN AND YANG DEFICIENCY 2) INTERNAL, DEFICIENCY, COLD, YIN *if you didn’t have cold for case #2, that is correct also – it is just closer to cold than hot

Qi/Blood/Body Fluids/Essence

Now that you understand cardinal symptoms, these next parts should go a lot faster. Then we can move on to actually breaking down case studies! In addition to the following, it is important to also review how each of these are made. Which organs do what in terms of, ex) making qi? (SP, ST, LU, KI) This is very useful for your point selection later. I.e., if you know that SP has to do with making qi, then SP3 (source) may be a great point to tonify qi in general.

Qi

It is important to understand the functions, as well as the dysfunctions of qi, blood, and body fluids. For example, if a patient has issues with frequent colds and flus, you can remember that qi ‘protects’ the body, so it may be an issue of qi (or it’s father, yang). Or perhaps a patient is digesting very slowly and they are malnourished and fatigued. You can remember that qi governs ‘transformation’, so it may be an issue with transforming food into qi. 5 Functions: i) Mov’t, activity ii) Warming iii) Protection (Wei) iv) Transformation v) Governs retention & containment 4 Dysfunctions: i) Qi deficiency ii) Qi sinking iii) Qi stasis (stagnation) iv) Rebellious qi Ok, cardinal symptom time again. A little hint is to take the functions, and add your imbalance on top of it, that should help you remember the symptoms. For example, if my example is qi deficiency, and I apply that to the ‘warming’ function, then we have ‘coolness’, ‘low heat’.

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Here is my example before you fill in the template under ‘Resources’. Qi Deficiency Cardinal Symptoms – Fatigue, shortness of breath (SOB), loss of appetite (LOA), coolness (not the deep cold of yang deficiency), frequent colds and flus, spontaneous day sweats, loose stool, frequent urination, pain is better with pressure and rest, worse after evacuation, weak digestion, pallor, t: pale with scallops (due to not being able to ‘contain’ the tongue), p: weak Again, take these symptoms and answer ‘why’ for each one. Why pallor? Because the warmth and therefore circulation is low, heat cannot rise to the surface of the body. Do this for every symptom – it is a great learning tool. Your turn! Grab your template, fill the ‘Qi’ section in now and come back to do a practice case. Using 8 Principles and the disharmonies of Qi only, please apply them to the following case (answer at the top of the next lecture): 3) Main Complaint: Insomnia History: One-year history of insomnia. The patient usually wakes between 3 and 4 AM and finds it difficult to fall back to sleep. He occasionally remembers his dreams. The patient feels that his level of mental energy during the day is poor, feels drowsy, and suffers from dizziness and poor memory. His food intake is less than average and he has abdominal distension after eating. He has general lassitude but is not restless and has no feelings of fever or cold. He is not thirsty. Urination and bowel movements are normal. Tongue: Pale body with a thin white coating Pulse: Thin

Blood

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4 Functions: i) Nourishing ii) Moistening iii) Material basis for mental activity (anchors shen) iv) Hair growth/quality of hair 3 Dysfunctions: i) Blood stasis (Stagnation) ii) Blood deficiency iii) Heat in the blood/skin Remember that blood is YIN and qi is YANG, so they have opposing, yet complimentary, functions. If you think back to your yin/yang charts from earlier, then you won’t get the functions of qi and blood confused. I’ll do an example with blood stasis: Blood Stasis Cardinal Symptoms – Stabbing/boring/fixed pain better with movement and slightly better with heat, purple colours (lips, skin spots, nails), masses and lumps, t: purple/purple spots, p: choppy Your turn! Grab your template and fill the ‘Blood’ section in now, and come back to do a practice case. Using Yin/Yang, Qi, and Blood please apply the applicable ones to the following case (answer at the top of the next lecture): 4) Main Complaint: Insomnia History: This patient has suffered from recurrent insomnia for several years. During the past week the insomnia has returned with difficulty in falling asleep and many dreams. The patient usually feels restless and has a sensation of heat in the chest. He also suffers from dizziness, poor memory, and dry skin. His mouth is dry and he likes to drink water. He has slight soreness and weakness in the lower back and the knee joints. Bowel movement and urination are normal. Tongue: Light red body with a thin yellow coating Pulse: Sunken, thin, and slightly rapid

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Body Fluids

3 Functions: i) Nourish muscles/orifices ii) Moisten skin iii) Strengthen brain and marrow 3 Dysfunctions: i) Stiffness/cramping in muscles ii) Dryness iii) Shen disturbances iv) Damp accumulation/phlegm *please review the differences between dampness and phlegm Your turn! Grab your template and fill the ‘Body Fluid’ section in now.

Essence

Essence has: 4 Functions: i) Governs growth, reproduction, development ii) Promotes KI qi iii) Produces marrow iv) Determines constitution 4 Dysfunctions: i) Developmental disorders ii) KI disorders iii) Marrow disorders iv) Constitutional Weakness Your turn! Grab your template and fill the ‘Essence’ section in now.

7 Emotions, 6 EPFs Gillian Marsollier, R.Ac.

Answers to Previous Lecture Case Questions – 3) INTERNAL, DEFICIENCY, COLD, YIN; QI DEFICIENCY 4) YIN DEFICIENCY; BLOOD DEFICIENCY

7 Emotions/6 EPFs

7 Emotions The most important ideas to know here are: • Which organs are affected • Which direction the energy goes • How the emotions can cause imbalance As this is just a review of the main points, I will keep this quick with the following chart: Emotion Organs Affected Energy Direction Anger LV (easy to develop into

LV overacting on SP/ST) Ascends OR Stagnates (depends if it is expressed or not!)

Joy HT Scatters and slows Sadness LU, HT Weakens, consumes,

dissolves Worry SP, LU Stagnates Pensiveness/Concentration SP Stuckness, Knots Fear/Terror KI Descends Shock/Fright KI, HT Suspends then scatters;

Becomes chaotic The emotions can go out of balance in 2 main ways: 1. In excess for a long period of time

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2. Sudden, extreme excess 6 (7) EPFs (External Pernicious Influences) The most important aspects to know here are: • Yin or Yang • Energy Direction • Cardinal symptoms • How the EPFs can cause imbalance. Yin/Yang Direction Cardinal Symptoms WIND Yang Up and out;

disperses Acute onset, rapid changes and movements, EPI symptoms (unless in the channel only)

COLD Yin Contracts, obstructs, stagnates

Cold, sharp/spastic pain better with heat, diarrhea, vomiting

DAMPNESS Yin Sinks, sticks (chronic)

Chronic, lingers, heavy symptoms, sticky discharges/secretions

DRYNESS Yang n/a Dryness of anything, dry couch with little or sticky sputum with occasional blood, easy to have asthma

SUMMER HEAT

Yang Upwards 4 bigs, can be severe and cause collapse, can combine with dampness

FIRE Yang Upwards 4 bigs (more severe),

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(stirs up wind also)

mania, delirium, bleeding, coma, dryness

PESTILENT Yang Moves quickly

Toxic, contagious, epidemic/pandemic Ex) Ebola, cholera, measles, etc

And how do these go out of balance? • Excessive and/or prolonged. • Out of context/season. • Anti-pathogenic/Zheng qi is weak.

Zang Fu Organ Functions/Etiologies/Zang Fu Syndrome Differentiations Gillian Marsollier R.Ac.

Organ Functions and Etiologies Ok, now that you have your cardinal symptoms down for all of the basics, it is time to memorize all of the functions of each Zang Fu, and also the REASON that can cause it to go out of balance. Once these are completed, when you break down a case, you look at: • Cause (etiology) • Organ Functions • Cardinal Symptoms And that will give you your answer! Ex) A patient complains of dry throat. He lives in Nevada and claims that the strong heat makes it worse. He also has dry skin and dry cough. He is starting to get some night sweats on his chest and warm in the evenings. On occasion, there is a small amount of stringy blood in his sputum. Here we see: • Etiology (cause) – Dry, hot environment • Organ Functions – LU – rules throat, skin, lungs • Cardinal Symptoms – dryness consuming yin – emerging yin deficiency Diagnosis? LU dryness and yin deficiency. Are you starting to see how this will go? Ok, memorize all of the following:

1) LU FUNCTIONS (7 main) Relations

1) Dominates qi (provides mov’t to essence & represents moving essence inwards) and controls respiration 2) Control channels and blood vessels (cold hands if LU qi xu) 3) Control dispersing and descending

-internally/externally related w/ LI; where LV stops, LU begins -6 channel, LU/SP Tai Yin color - white season - autumn taste - spicy/pungent

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4) Regulates the water passages 5) Dominates skin and body hair 6) Opens into the nose 7) Houses the Corporeal Soul (PO)-spiritual aspect ETIOLOGICAL FACTORS: 1) Exterior Pathogenic Factors: easily attacked by EPFs 2) Emotional Strain: esp grief, sadness. 3) Diet: easily dried out and dampened. White foods in general help balance (ex) turnips, radish, and pears.

orifice - nose fluid - mucous emotion - LU grief/sadness – ability to feel pain (Po) sound - weeping body part - skin/body hair energy clock - 3-5am body sound - coughing climate - dryness smell - rotten -LU hates cold -governs voice

2) SPLEEN FUNCTIONS (9 main) Relations

1) Governs transformation and transportation – separates distilled food essences from ST to help create qi 2) Controls ascending of qi 3) Controls xue – helps make qi and xue; keeps xue in vessels (holds it in) 4) Controls muscles and 4 limbs 5) Opens into mouth; manifests in lips 6) Controls saliva 7) Controls raising of qi 8) Houses Yi (intellect) 9) Affected by pensiveness ETIOLOGICAL FACTORS: 1) Exterior Pathogenic Factors: easily attacked by dampness 2) Emotional Strain: esp pensiveness, worry 3) Diet: prefers ‘warm’ foods (both temp and energy) – cold/raw/dairy

-Earth element – cycles, natural circadian rhythms, patterns -colors – yellow, orange -season – late summer -organs – ST/SP(int/ext relation) -6 channel theory paring – LU Hand Tai Yin -time- 9-11am -flavour – sweet; diabetes, hypoglycemia, cravings -orifice – mouth -fluid secretion – saliva - body part – flesh/musculature – tone/texture -emotions – sympathy/compassion – ideas, inspiration, pensiveness, thinking, insight -association with mother -imbalance – obsession, dogma, over thinking, worry, needy, can’t accept sympathy or always looking for sympathy, hypochondriac, eating

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excess can impair T & T function

disorders -sound – singing/can sound whiney; also belching associated with earth -smell – sickeningly sweet -climate – dampness/humidity -energy direction – upwards

3) HEART FUNCTIONS (5 main) Relations

1) Governs xue and xue vessels (therefore hair along w/ KI essence) 2) Houses the shen/spirit/mind 3) Opens into the tongue 4) Governs sweating 5) Manifests in the complexion ETIOLOGICAL FACTORS: Emotional Strain: all emotions affect the emperor/heart. Esp trauma/shock. Blood Loss – especially gynecological

time: 11am-1pm emotion: joy/sadness season: summer sense: speech - can be rapid if shi (remember it connects with the tongue) smell: burnt/scorched flavour: bitter sound: laughter – can be excessive/inappropriate -int./ext. relation - SI foot tai yang -6 channel theory pairing - KI shao yin -ascending, attracting, illuminating, lively, vital, insight, clear direction, expression of ideas and feelings, ability and courage to have relationships with others, warmth, touch, compassion, governs moods Fire needs warmth/love -element that coordinates all the others – SUPREME RULER/CONTROLLER/EMPEROR SHEN: ‘mind’, ‘spirit’ – spacious, clear, luminous like the sky -mov’t of fire is upwards and outwards -heat in body disturbs shen/spirit IN BALANCE: radiates outwards like light

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MOST COMMON PATHOLOGIES 1) HT and CHEST DISORDERS: pain, HT stasis, palps 2) SPIRIT DISORDERS: insomnia, epilepsy, mania, psychosis, depression 3) Diseases along course of channel.

-physically fit, good circulation, free flow of sweat, clear head, general sense of well-being -requires adequate xue/yin to nourish HT; if xu – disturbs HT – insomnia, etc -manifests in the complexion IMBALANCED: strongly affected by other people’s emotions (helps balance emotions with LV) – disturbance – anxiety, panic -constant red face – pathogenic heat in organs (esp HT/ST/LV) -absence of color in face (can be somewhat ashen) – HT yin/yang xu -taste is bitter, excess HT may gave a bitter taste in mouth (esp in the morning after a poor night sleep) -too much joy and excitement – energy rises and scatters HT qi – inability to concentrate -fright affecting HT – easily startled, palps, insomnia, mental restlessness, pulse vibrates, short, fast, slippery -xu – grief, lack of joy

4) KIDNEY FUNCTIONS (9 main) Relations

1) Stores essence (jing) and governs birth, growth, reproduction, and development 2) Produces marrow, fills up brain and controls bones/teeth 3) Governs water 4) Controls reception of qi 5) Opens into ears 6) Manifests in hair 7) Controls 2 lower orifices

time: 5-7pm emotion: fear season: winter sense: hearing smell: putrid flavour: salty sound: groaning, monotone -int./ext. relation – UB foot tai yang -6 channel theory pairing – HT hand shao yin

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8) Houses willpower 9) Controls minister fire (ming men, gate of life) MAIN ETIOLOGIES: 1) Hereditary weakness 2) Emotional Strain 3) Excessive Sexual Activity 4) Chronic Illness 5) Overwork 6) Old Age Spiritual Capacity: WILL - same as UB

5) PERICARIDUM MAIN FUNCTIONS (3 main)

Relations

1) Protector of HT; invasions of EPFs 2) Houses the mind; mental-emotional problems 3) As the centre of the thorax; channel pathology *3 main factors differentiating PC from HT: 1) Involvement of PC channel in chest 2) Involvement of LU channel: SOB, cold hands 3) Often involvement of LV; irritability, h/a MAIN ETIOLOGY: 1) Pathogenic Factors

time: 7-9pm emotion: joy/sadness season: summer sense: speech smell: burnt flavour: bitter sound: laughter -int./ext. relation – SJ hand shao yang -6 channel theory pairing – LV – foot jue yin Spiritual Aspect: literally and figuratively protects HT from outside blows -often PC issues can be related to childhood betrayal, hurt, sexual abuse - relationship issues

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6) LIVER FUNCTIONS (8) Relations

1) Stores xue 2) Ensures patency 3) Controls sinews 4) Manifests in nails 5) Opens into eyes (know eye chart!) 6) Controls tears 7) Houses HUN 8) Affected by anger GENERAL ETIOLOGY: 1) EPFs – esp wind and damp 2) Emotions – anger, worry, sadness 3) Diet – esp too many hot energy foods, or inadequate blood building foods 4) Xue Loss

time: 1-3am emotion: anger season: spring sense: sight smell: rancid flavour: sour sound: shouting -int./ext. relation – GB foot shao yang -6 channel theory pairing – PC hand jue yin

The Functions of Six Fu Organs ORGAN FUNCTION NOTES ST 1) Controls the rotting & ripening of food

2) Controls the transportation of food essence 3) Controls descending of Qi 4) The origin of body fluids

Working together with Spleen; complex relation with

SI 1) Controls receiving and transforming 2) Separates fluids

Coupled with Heart – Fire element Controlled by Kidney Yang Like Lungs – excretion organs

UB 1) Removes water by Qi transformation (Stores fluid and transforms it into urine, excretes)

Coupled with Kidneys - Water Controlled by Kidney Yang

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SJ 1) Avenue for the original Qi movement 2) "Controls the water passages" -Upper B. - Qi ascending and dispersing. -Middle B.- ascends pure Qi, descends dirty Qi -Lower B. - excrete 'dirty' and urine

Coupled with Pericardium – Fire No form, more of a concept/function Thoracic, abdominal, pelvic cavities

GB 1) Stores and excretes bile (extraordinary/curious as only one to store a vital essence) 2) Controls judgment 3) Controls sinews

Coupled with Liver - Wood element - shares many functions

LI Re-absorb water; receive food and drink ‘Garbage man’; excretes stool

Couple with Lung – Metal Receives qi from LU

Zang Fu

Just like you have been doing for most of the past few lessons, I know want you to fill in the CARDINAL SYMPTOMS for all of your main zang fu patterns. Keep in mind that your text may have a couple more or different ones so please feel free to add those in. The key here is to only put down the symptoms that will make it DIFFERENT than the other patterns. Yes, there will be a bit of overlap, as I said before, you need a small group of symptoms. So, don’t worry about a bit of overlap. Here is my example: HT Blood Stasis Cardinal Symptoms – Stabbing chest pain that may radiate to sternum or down left arm/shoulder, cyanotic/purple lips, t: purple, p: choppy Note that all the symptoms are there, but the main ones are and that is the key here. You will notice on your template ‘a feel for’ boxes also. These are general symptoms that will point you towards an specific organ issue. Good to memorize also.

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A Hint: if you are using Giovanni Maciocia’s Foundations, you will see drawings of people in the zang fu pattern section with words around them. Those are the cardinal symptoms. He calls them ‘key symptoms’. Your turn! Grab your template and fill in the ‘Zang Fu section in now.

Channel Syndromes

Ok, I have ONE more thing to say. Do recognize the difference between an ORGAN (Zang Fu) syndrome and a CHANNEL (Jing Luo) syndrome. You just completed your zang fu ones, but a channel syndrome is recognized like so: There are no related internal symptoms. It usually comes on quickly and/or from an external source. This does not mean that they don’t have any internal symptoms, as most people do. They just aren’t RELATED to the onset of the channel pattern. For example, perhaps you are treating a patient for white leucorrhea. She doesn’t seem to have any other signs of dampness or SP deficiency, in fact, she is quite healthy! But, she tells you that it has only been one week and that she was fly fishing in Arctic waters. Ahhhhh, this is a CHANNEL issue. Did you guess it? If you guessed COLD and DAMP entering the LR or KI channel, then you are correct! Please grab your text book and fill in the blank template for ORGAN FUNCTIONS and ETIOLOGIES. These are key to point you towards which organ you are treating, and to find your CAUSE of the syndrome in the first place If this works for you, then I have a way that you can put it all together with ease! For example, if you have a patient who recently had their spouse pass away (first thought here should be SADNESS/GRIEF = Qi Consumed/Weakened/Dissolved plus LU/HT). She claims that she has been

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sick with a weak cough (deficiency, probably LU) for 1 month (since spouse passed – sudden extreme emotion = causes imbalance). Additionally she has spontaneous sweats (qi deficiency), diarrhea with no smell and fatigue after (SP qi deficiency), she looks pale (deficiency), feels slightly cool all the time (qi deficiency) and says she is coming for fatigue (qi deficiency). I’ll bet you are screaming out right now LU/SP qi deficiency from grief! If so, Bravo! But, do you see how it was your strong foundations that got you there? This was an easy one though, most cases that you see in clinic, or on the case study exam, are much more complex than this. I am going to show you this case breakdown method a bit later again. Let’s now move on to our order and definitions.

Ben/Biao Gillian Marsollier R.Ac.

Your last step before treatment is figuring out what to treat first, second, etc. BEN BIAO (Root/Branch ) Three possible treatment principles: 1) Treat Root Only - Best strategy if clinical manifestations are not too severe ex) Tonify SP for damp 2) Treat Both Root And Manifestation - Especially in chronic cases where symptoms severe or when branch will worsen the root ex) Elderly person w/ SP deficient but severe diarrhea, diarrhea and SP both treated 3) Treat Manifestation First, Root Later - Acute cases or symptoms severe - ex) Very heavy period, stop bleeding MULTIPLE ROOTS AND MANIFESTATIONS -most common, due to complexity of most clinical cases. Three possible situations: 1) Multiple Roots, Each Giving Rise To Different Manifestations - Very common over lifetime ex) LR fire and invasion of wind causing bi pain (both roots) - probably will result in damp heat bi 2) One Root Giving Rise To Different Manifestations - ex) SP deficiency causing edema and blood deficiency 3) Root Coincides W/ The Manifestation - When treatments caused by external physical trauma. ex) Knee injury causes qi/blood ss - happen at same time ZHENG QI AND PATHOGENIC FACTORS

1) TONIFYING ZHENG QI

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i) most effective in deficiency conditions without any pathogenic factors, Ex) pure xu pattern - Sp qi deficiency; Blood deficiency, etc ii) OR, in excess/deficiency patterns with predominance of deficiency (if excess predominant, tonification of qi may tonify PF). Ex) Sp qi deficiency with slight dampness. Only need to tonify SP qi and damp should clear. Ex) ST/SP deficiency allowing invasion of LR qi (ST qi weak allowing invasion) therefore must strengthen ST qi so that LR qi cannot invade it (feeling the pulse is a good indicator of which to choose - weak for this

example rather than wiry) 2) EXPEL PATHOGENIC FACTORS

- only in pure excess patterns w/ presence of exterior or interior PFs -expelling the PF will remove any obstructions for the zheng qi and therefore tonify it ex) person with somewhat weak qi has wind-cold invasion - must remove pathogenic factor and tonify qi after EPI has been expelled

ex) LR fire - must expel fire to relieve symptoms 3) TONIFY ZHENG QI AND EXPEL PFs

1) Used with exterior cases ONLY if person is EXTREMELY weak or elderly - ex) EPI wind invasion with VERY weak qi, must tonify qi first and then expel PF (very rare) 2) Used in mixed excess/deficiency interior cases ex) Sp qi xu w/ damp - tonify UB-20, ST-36, reduce SP-9 and SP-6 -can have ‘residual PF’ - EPI not expelled, sneaks inwards, and lurks inside ex) fatigue, feeling of heat, recurrent sore throats, red tongue w/ thin yellow coat btwn tip an centre and sl rapid pulse. (Chronic Fatigue Syndrome is an example)

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Breaking Down a Case, Definitions/Order Gillian Marsollier R.Ac.

Congrats! You got all of the boring (yet incredibly essential) stuff out of the way. Now you are ready to learn the proper steps to breaking down a case. Let’s jump right in to it… Here is the order in which you should break down a case. 1. Chief Complaint (CC): The reason the PATIENT is coming that day* (with a few

exceptions – see the ben/biao lesson for details). CIRCLE THIS.

2. Etiology(s): The CAUSE of the imbalance(s). I have students change this word to CAUSEology for memory sake. On occasion, it isn’t clear from the outset, but with good history taking, you should be able to find it, or at least the greatest possibilities. SQUARE THIS.

3. Syndrome Differentiation and Pathogenesis: Syndrome differentiation is the TCM pattern(s) you have concluded. Pathogenesis is the evolution of the imbalance. UNDERLINE SYMPTOMS TO HELP FIND THIS.

4. Treatment Principles (TP): How you are going to address the syndrome differentiation.

5. Points, Techniques, Modalities: The acupuncture points you have chosen for their treatment. The actual needle techniques you will employ. Any adjunct methods of treatment you will use.

6. Treatment Plan: The plan you decide for the patient’s path to healing. Includes approximately how many treatments, how many times/week, and over what period of time (EXTREMELY important for patient healing and to maintain and busy clinic). How your treatments are going to unfold. Ex) After the damp has cleared from the middle jiao, I would focus on tonifying and warming SP yang. Also include lifestyle and diet in this section.

7. Biomedical Red Flags: Any symptoms or set of symptoms that fit with a Western disease pattern set that requires referral to a physician. Always watching for biomedical red flags for referral.

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Let’s look at these with a bit more detail: 1) Chief Complaint (CC) - The reason the PATIENT is coming that day. It certainly isn’t uncommon to be wanting to or accidentally treat something other than the reason the patient came. Remember that you must honour the patient’s reason for coming. If they are coming for a sore knee from a rugby accident but have severe IBS – you treat the knee. BUT, while you are treating the patient, it is a great time to talk about how TCM treats IBS and educate them on what you can do. It will be up to the patient if they wish to follow that route, but at least they understand the TCM option. But treat that knee first! Know there are a few exceptions to the CC rule. This comes down to a ben/biao issue. If treating the branch is necessary to treat the root, then you must treat the branch. For example: Patient sees you for dry eyes and blurry vision. Your diagnosis is LV blood deficiency. But your root is due to blood loss at menstruation time (menorrhagia). If your patient comes in during a heavy day of her period, your CC for that day must change to heavy blood loss. Diagnosis: xue heat (ex), TP: Stop bleeding. As you can see, there is no point in putting money in the bank that day when they are withdrawing much more than you can put in. You must stop and regulate the heavy bleeding in order to treat the root. One more instance would be an EPI. We all know that is a trump card for treatment. If you start treating your knee patient for IBS and they come in with a terrible day 2 of a cold, you must treat the cold (EPI). 2) Etiology(s): The CAUSE of the imbalance(s). I have students change this word to CAUSEology for memory sake. On occasion, it isn’t clear from the outset, but with good history taking, you should be able to find it, or at least the greatest possibility(ies). What are the TCM etiologies? The 6 (7) Exogenous/External Causes: These are: wind, cold, dry, fire/heat, summer heat, damp, pestilent (epidemic; incredibly virulent

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diseases. Ex) Ebola, AIDS, Cholera, SARS), miscellaneous. N.B. Miscellaneous causes are some of the most common to treat these days – they include: STRESS, Diet (includes food retention), medications, chemo/radiation, injury, poisons, parasites, excess/deficient physical or sexual activity. The 7 Internal Causes: These are the 7 emotions: anger, sadness, joy, worry, pensiveness/concentration, fear/terror, shock/fright. How do these seemingly ‘normal’ factors go out of balance? • Excessive and/or prolonged. • Out of context/season. • Anti-pathogenic (Zheng or Body or Upright – I know, TCM has WAY too many

names for everything – it’s a translation issue) qi is weak. 3) Syndrome Differentiation and Pathogenesis: Diagnosis is the TCM pattern(s) you have concluded. Pathogenesis is the evolution of the imbalance. You may be wondering why these two are included together in step 3. It is certainly case dependent, but for the most part, you will be finding your diagnosis(es) and pathogenesis concurrently. Let’s break them down: Diagnosis: There are 3 main types of diagnosis with 2 of them being part of your treatment plan. Primary Diagnosis: Your primary diagnosis(es) will reflect what you are treating that day. If your patient has knee pain, but has an EPI that day, then your primary diagnosis shall read: EPI wind-cold Secondary Diagnosis: Your secondary diagnosis(es) are either: less important branches off of your primary diagnosis; or are separate patterns all together that may or may not be playing a part in your primary diagnosis. If you are confused if a pattern is a secondary diagnosis, then you should

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ask yourself, “If I treat this pattern, will it make a difference in the results outcome?” If you answer no, then it is most likely a secondary diagnosis. More often than not, your secondary diagnosis(es) is taken care of when you treat the primary diagnosis(es). If you have treated the primary and the secondary patterns still exist, then they can be addressed. Of course it isn’t completely this simple. Ben/biao comes into play here and you need to consider if you treat primary only, secondary only (branch is too distressing/acute), or primary and secondary concurrently. This was addressed in the ben/biao section. Differential Diagnosis: This is what I call the ‘close but no cigar’ diagnosis. It may seem silly to include this diagnosis, but it is actually a natural occurrence. A differential diagnosis is basically all of the patterns that were considered yet discarded as part of your primary/secondary diagnoses.

For example: A patient comes in complaining of epistaxis. They get a bleeding nose when they are stressed or angry, have a huge temper, red face, severe constipation that is smelly and difficult to pass, dark yellow, scanty urine, high blood pressure, big bouts of vertigo, a flooding and rapid pulse, and a dark red with a thick, dry yellow coat. In your mind right now, you should be considering: LV heat, LV fire, LV yang rising, HT fire, ST fire, etc… But which one wins out? Well this becomes a case of knowing your CARDINAL SYMPTOMS like the back of your hand. We covered that earlier (please ensure you complete that chart before taking on any cases later in the book). The answer is LV fire because the cardinal symptoms: of bleeding, huge temper, SEVERE constipation and vertigo plus the tongue and pulse are all cardinal symptoms of LV fire. And the differential diagnoses? Well, that is the ones remaining that you were considering – LV heat, LV yang rising, etc… Pathogenesis: The evolution of the imbalance.

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This is basically how a patient got from A to B (or C, D, even Z for that matter!). This sounds easy enough, but in order to accurately understand their progression, you must understand your foundations. How exactly do LR and LU work together? What is the relationship between SP and HT again? How do those relate on the 5-element cycle? This is such an important section, that a whole chapter and video are dedicated to it. Please read on for full details. 4) Treatment Principles (TP/POT): How you are going to address the diagnosis(es). This needs to match your diagnosis. It shouldn’t include anything else. Ex) If you diagnose a diarrhea patient with LR qi stagnation causing SP qi deficiency, then your treatment principle must read: Move/Circulate LR qi; Tonify SP qi; Stop diarrhea. You cannot add in other areas you are thinking of treating also. You cannot add ‘Clear HT fire’, for example, in your treatment plan as it is not in your diagnosis (meaning primary diagnosis – the reason your patient is coming in that day).) Keep It Simple, Keep It Clean. That being said – always make a space on your first intake forms for you to talk to yourself. To make notes for the future. So, it may look like ‘stop bleeding’ today, but in your notes section it may say ‘consider tonifying LR blood and using LR8/SP6’. This is helpful not only for your memory, but also to keep your treatment plan ticking along and organized. Of course, you always go into the treatment room fresh and ready for wherever that patient is that day, but for the most part you can make a plan and generally stick to it. 5) Points, Techniques, Modalities: The acupuncture points you have chosen for their treatment. The actual needle techniques you will employ. Any adjunct methods of treatment you will use.

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Now, here is the eternal acupuncture challenge. Point selection and pulse. Once you have mastered breaking down your case studies, then your mastery of acupoint selection and reading the pulse should be next in line. Will you ever master it in this lifetime? Perhaps, but more near the end of it, so be patient with yourself. There is so much to understand about points and pulse at the deepest of energetic levels, that I believe that 95% of us scratch the surface with each patient. But, I digress and say, let me tell you what I know now. But be ready to learn more in your future. Point selection general rules: • Around 10 points TOTAL/treatment. Not 10 acupoint choices, but 10 needles

total. This is such a general rule that I am now going to break it. A few times… • Under 10 points for weak or very sensitive patients • Over 10 points for purely excess patients (which is like seeing a Yeti in the West –

most people have a level of depletion as we like to go, go, go) • I personally believe that you can use as many non-meridian, ah-shi points and

trigger points as you wish, as they are not in actual meridians. I have never seen a patient weaken from this. That being said, if they are incredibly weak, I always stick to under 10 points as their peripheral qi might be all they have. Once you needle into a meridian though, then you are shifting their de qi – THOSE needles need to be under 10 total.

• Know your point energetics and empirical points more than your point indications

• Bi-lateral needling is most common for tonifying treatments • Contra-lateral needling is most common for reducing. Here are the main methods to tonify and reduce:

METHOD TONIFYING REDUCING

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TX Duration Short-less than 20 min Long-more than 20 min

Twirling and thrusting 9x 6x

Rotating the needles Clockwise (thumb out) Counter-clockwise (thumb in)

Direction of the needling

With meridian Against meridian

Respiration and needle insertion

Exhale on insertion Inhale on removal

Inhale on insertion Exhale on removal

Insertion/Removal of the needle

Slow insertion, quick withdrawal + cotton ball covering

Fast insertion, slow withdrawal - no covering point with cotton

Lifting and thrusting Forceful thrusting, gentle lifting

Gentle thrusting, forceful lifting

Amplitude Small amplitude Large amplitude

There are 1001 different acu systems to work with when it comes to choosing your points, so I will stop here. For your exam, be basic, be TCM. 6) Treatment Plan: The plan you create for the patient’s path to healing. Includes approximately how many treatments, how many times/week, and over what period of time. (EXTREMELY important for patient healing and to maintain and busy clinic) This is definitely the trickiest part for any new practitioners/student clinicians, as you haven’t treated long enough to know how long you will be treating someone. Here are some general rules: First let’s define acute, sub-acute, chronic. Acute: under 3 months Sub-Acute: 3-6 months

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Chronic: over 6 months 8-10 treatments is a round. 10 in China, I do 8 (as I find this is the average that most patients need in full for most conditions). I tell patients that we will do 4 treatments, re-assess – if they have improved, continue, if no improvements, change the strategy and try another 4. At the 8 mark, we re- assess and see if we need to continue or not. Ideally we could see most patients a couple times/week, but that is not always possible in most clinics, so once/week is the average. So… 8 treatments: -Ideally about 1-2x/week for chronic (unless patient very weak or you are working through big emotional blocks – then 1x/week is good to start) -Definitely not less than 1x/week (ask them to book at a later date when they have time if they cannot make that work now – of course they can book whenever they want, but it is much, much less effective with large gaps between treatments). It will cost them more in the long run to do it that way. Acute treatments should be daily or at least 2x/week for around 1-3 weeks. (This is incredibly dependent on what happened). After they are better, ask to see them in a month or if the symptoms start creeping back. In fact, I often say, “book for 1 month from now – if you feel great with zero symptoms, cancel that appointment, but I would rather you had it if you need it for now”. You will be surprised with how few patients cancel that appointment, as even if they are feeling better, they often want to move on to treating a new syndrome. Many chronic conditions can take 60 plus treatments. Yes, you read that correctly – and still won’t elicit cure. But you can sure make a person’s life a heck of a lot better. Ex) macular degeneration I have a lot more to talk about here in setting up treatment plans for best healing and a successful clinic, but we will stick with our Case Studies theme for this course. Biomedical Red Flags: Any symptoms or set of symptoms that fit with a Western disease pattern that requires referral to a physician. Always watch for biomedical red flags for possible referral.

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This is a really key area that is not the scope of this book to go into. You need to have strong knowledge of your biomedical information (pathophysiology) and what symptoms constitute a ‘red flag’, i.e. a concerning set of symptoms that may need Western medical care. It is true that we cannot, and should not (as it isn’t our training), diagnose in Western terminology (cancer, stroke, MS, etc.), but what we can and SHOULD do is recognize what the signs are for as many illnesses as your brain can handle, so that you can refer your patient out when you see those symptoms. You don’t need to stop there! The more you learn about Western pathology, the more you will help catch big illnesses that need surgery or strong meds faster (yes, I those are very necessary in some cases). Also, when in doubt – ask. If you need to call their family physician, if you work with a naturopath – ask. They can help you and therefore help your patient get the proper care they need.

Pathogenesis Web Gillian Marsollier R.Ac.

5-ELEMENT CYCLE Now for those who think that 5-elements is only for emotional treatments, I’ll let you in on a little known secret: Your 5-element cycle is the best way to find your pathogenesis. It’s true. All of the relations between organs are there. First we have to look at the BALANCED cycle. The Sheng (Generating) Cycle is the green arrows, and the Ke (Control) Cycle is the blue arrows.

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There are 4 main IMBALANCED cycles are: • Overacting (blue arrows also, only very excessive) • Insulting (red arrows) • Mother Taking From Child (green arrows – mother is weak and is weakening

the child). Ex) SP is deficient first, and then LU becomes deficient later.

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• Child Taking From Mother (green arrows – child is usually weak and taking energy from the mother) Ex) LU is deficient first, and then SP becomes deficient later. BUT, it isn’t always deficiency taking energy. Here is another common example: LR heat first, KI yin deficiency second, as the child takes the KI yin to try and cool itself

These are the basics. Ok, now what? THE PATHOGENESIS WEB Since pathogenesis is the EVOLUTION of their imbalance(s), we need to understand what happened when and why (etiology), and what pattern emerged around that time. Please refer to the video for the rest of this section. PUTTING IT ALL TOGETHER Now that you have drawn your web and your 5-element cycle, you can confidently determine your Primary Diagnosis, Secondary Diagnosis, Etiology, Treatment Principle, and then choose your points and create a powerful treatment plan. You should, at this moment, be saying to yourself, “Ok, ok, I didn’t know my foundations as well as I thought”, as getting all that info in your head is by far the most difficult step. How the heck did the patient get from SP qi deficiency to LV invading LU? Well, you need to know how they relate along the cycles, etiologies, how qi and yin and yang and blood all intermingle dependent on what organ you are talking about, and the list goes on. But, that whole list is foundation.

Case Study Template Gillian Marsollier R.Ac.

Please refer to the video for this section also, so you can see this section explained out. But, here is an example of how to use the template – REMEMBER, the template is only useful for difficult cases! CASE A 46-year old woman has complaints of severe night sweats. She has had them for 1-year. She is also hot a night. She has a history of very heavy periods ever since menarche and has a busy lifestyle. She has had low back ache for 6 months also that is relieved with rest. For many years now, she has had floaters and poor quality nails and hair. Recently (past 2 months), she has noticed an increasingly poor memory and palpitations after her period. Her tongue is red with little coat, and has pale sides. Her pulse is thready and rapid. Case Breakdown Notation - CC: Circle, Etiology(s): Square, Symptoms: Underline

List CC (Chief Complaint): Night sweats List the Etiology(s): age (46); heavy periods since menarche List the case symptoms in column #1 and add in all the syndrome differentiations that seem applicable in column #2. In column #3 you can justify your answers. When you are finished, go back through column #1 and add the numbered order the symptoms arrived (this can be somewhat general). Example: 1,Floaters; 2, LR blood def.; 3, LR rules eyes, LR blood nourishes eyes.

1) Signs and Symptoms: (Plus number order)

2) Possible Syndrome Differentiations:

3) Reason for Signs/Symptoms:

1, floaters blood def LR blood nourishes

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eyes 2, Freq waking with a start; restless

Yin def Yin grounds yang

2, Low back ache KI def KI rules low back 1, light periods LR blood def LR rules amount of

blood flow 3, poor memory HT blood def HT governs blood

and mind 3, mild palps after period

HT blood def HT blood def at that time causes weakness in chest

1, poor quality nails and hair

LR blood def Blood def

LR blood nourishes nails Blood nourishes hair

List the main syndrome differentiations that emerged in numbered order (according to their history – which came 1st, 2nd, etc.). Note that easy cases often don’t have a numbered history among the symptoms. Add the symptoms that support your syndrome differentiations beside.

Number Syndrome Differentiation (ex) 1) LV heat; 2) Heat in the blood; 3) LV wind, etc.

1 LR Blood def

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2 KI Yin def 3 HT blood def

TCM Illness: (ex) Lin Syndrome, Asthma, etc. Night sweats Draw your 5-Element chart and place the numbers and patterns at their corresponding element. Then, create your pathogenesis using the 5-Element imbalance sequences (overacting, insulting, mother not nourishing child, child taking from mother.) Please note that you can skip this step with simple cases.

3) HT blood def

í

1) LR blood def é

ë 2) KI yin def

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Draw your pathogenesis in arrow form, including your etiology(s) and multiple roots, if present: Heavy periods à LR blood deficiency à Busy lifestyle à KI yin deficiency worsened by child taking from mother (LR blood deficiency taking KI yin) à mother not nourishing child à HT blood deficiency worsened by KI yin being deficiency Diagnosis (remember your Ben/Biao rules here.) Sometimes this question is completed either before the pathogenesis, or they emerge at the same time.

Primary Secondary Differential LR blood def HT blood def LR yin def KI yin def HT yin def

Treatment Principle (MUST match Diagnosis): Tonify LR blood; Tonify KI yin; Stop sweating Point Selection (5), Techniques, Modalities: Acu Points

Techniques Modalities (if applicable)

LR 8 Tonify none KI 6 Tonify none LI4 Reduce (combo with KI7

to stop sweating

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KI7 Tonify CV4 Tonify yin and blood Treatment Plan (amount and frequency of treatments; order of treatments; lifestyle/dietary advice): I would do 2 treatments/week for 8 treatments and re-assess at that point. I would ask her to rest more in order to assist her body in regenerating yin and blood and to try more restful activities like a calm yoga, meditation, etc. I would ask her to eat more meat and beans (if she doesn’t eat much), and darker foods such as greens and berries to tonify her blood and yin. She should avoid too many foods on the extremes of hot or cold as hot would deplete yin, and cold would deplete blood. She should keep bitter foods low as they deplete blood and yin. If the HT blood is still deficient once the LR blood and KI yin are stronger, I would also add in points to tonify it. (To students: If this lady complained of severe sweating, then our treatment principle would be only to STOP SWEATING. Once that is under control, we would move to tonifying her blood and yin. That would be a ben/biao issue!) Biomedical Red Flags/Western Illness (if applicable): Possible peri-menopause – send for testing

Quick Sheet + Summary Gillian Marsollier R.Ac.

Breaking Down a Case for Written Exam – Quick Sheet Here is the order in which you should break down a case: Chief Complaint (CC): The reason the PATIENT is coming that day (with a few exceptions – EPI or branch too distressing and will worsen the root if not addressed) Etiology(s): The CAUSE of the imbalance(s). Diagnosis and Pathogenesis: Diagnosis is the TCM pattern(s) you have concluded. Pathogenesis is the evolution of the imbalance. Treatment Principles (TP): How you are going to address the diagnosis(es). Remember that your TP should reflect your diagnosis! Don’t add patterns in. These will be obvious choices on the Written exam, but key to remember for the Case Studies Exam: Points, Techniques, Modalities: The acupuncture points you have chosen for their treatment. The actual needle techniques you will employ. Any adjunct methods of treatment you will use. Treatment Plan: The plan you decide for the patient’s path to healing. Includes approximately how many treatments, how many times/week, and over what period of time. Biomedical Red Flags: Any symptoms or set of symptoms that fit with a Western disease pattern set that requires referral to a physician. Always watch for biomedical red flags for referral. ALSO, remember to: • Put a square around your CC. (Remember, you treat their CC 95% of the

time, unless there is an EPI or very distressing branch issue) • Circle your etiology(ies). • Underline all symptoms and relate them to most likely pattern/organ. • Look at your 5-element cycle and ask, ‘which came first’ – then go through the

cycle to see how each diagnosis relates to/caused the next. • Use the rules of ben/biao to decide what you will treat that day. • Have your TP reflect your diagnosis exactly.

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• Remember that your most important areas to study for cases are: foundations, cardinal symptoms of patterns, yin/yang, qi/blood/essence, damp, EPFs, functions of the organs. THESE MUST BE 100% memorized!

*If you have a very simple case, many of these steps can be skipped for the sake of time. But if you are unsure at all – go through each step! Now is the time in the course to go through the Case Study Breakdown Demonstrations, Practice and then your Case Study Exam. Students in 2nd or 3rd year not writing exam this year – Try not using any books or notes at first. If you find some cases too difficult, please pull out your materials and use them for each case. You are still learning, so you aren’t expected to break down advanced cases yet. There is no need to worry about time limits at this point. Studying for Board Exam Students – Please put your books and notes away. Any cases with open-ended questions you have 15 minutes to complete. Any multiple-choice cases, you have 2 minutes to complete. Please time yourself. Practitioners – Please try not to use your notes or books at first. It will be a good test to see where you need to focus your reviews. You can decide whether or not you want to time yourself. Remember to use these methods for the first year or more in your clinical practice so the steps become cemented in your brain!

GOOD LUCK!

References Gillian Marsollier R.Ac.

• Yin/Yang Bar Chart: http://bodyaligntips.com/wp-content/uploads/2013/12/YInYangConditions.jpg

• 5-element cycle: http://www.sacredlotus.com/images/tcm/fivel-element-cycle.gif • Felix Mann, Acupuncture – Yin/Yang functions • TCM Tests – some cases taken from • Acupuncture Relief Projects – some cases taken from

http://www.acupuncturereliefproject.org/about-this-project/evidence/case-studies/44-case-studies/175-low-back-pain-with-radiation

• XueMai, Acupuncture Patterns and Practice – 4 cases taken from http://www.sacredlotus.com/go/foundations-chinese-medicine/get/zang-fu-organ-relationships#htlu - Zang Fu Organ Relationships