This content details a patient consultation for a Traditional Chinese Medicine (TCM) viva exam, focusing on a patient presenting with a persistent three-month headache, accompanied by various other symptoms, and exploring their medical history, lifestyle, and TCM-specific diagnostic information.
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so this is your patient information form
you're only allowed to read this speaker
more than others your total time is one
half an hour because addition time
maximum half an hour
okay good morning thank you for coming
into being my patient today for my viva exam
exam
uh you've met dr lee my name is dawn
and dr lee will be my assessor for today
and are you all right with dr lee observing
observing
yeah sure okay great welcome so before
we get started i just wanted to let you
know that a consultation and treatment
generally takes about one and a half
hours and because this is an
exam that assesses both acupuncture and
chinese herbal medicine
i'll be providing both of these
modalities to you today
this is working with your plants sure
does okay great
thank you so is this your first time
visiting sitcm student clinic
yes it is okay welcome and do you have
any questions before we get started
not yet no okay great uh so chinese
medicine takes a holistic approach to
health and we believe that each bodily
system is interconnected
and that every person's situation is unique
unique
so this means that we may need to ask
you many questions before we can make a diagnosis
diagnosis
and is it okay for me to start asking
you questions now yeah sure
okay great so we'll start off by going
through your indemnity and release form here
here
and then your patient information form
the indemnity
and release form says that right here
any information that you share with us
maybe share with other health
professionals to manage your condition
do you have any concerns about that no no
no okay
and after the consultation we will also
offer you some treatment options
so as with all treatments acupuncture
and herbal medicine
may produce side effects so possible
side effects are listed on the form here
and include but not limited to
minor bleeding or bruising minor pain or soreness
soreness
infection nausea vomiting diarrhea
and in rare situations perforation of
internal organs
any pre-existing conditions may also
cause other adverse events
do you have any questions about this
information um
those things don't often happen do they
no they don't
no so don't worry yeah that's fine okay great
great
so the form also says that you may
experience any side effects
and you may need to report them to us in
rare situations you may also need to
contact someone else for example
in an emergency you should call an
ambulance do you understand this
sure do okay and you have any questions
about this form or anything else before
we move on to review the patient
information form
so now i'd like to clarify a few things
from your patient information form
any allergies no okay
family history my mother has had ibs for
20 years
okay any history of surgical operations
or procedures
i did have an appendictomy when i was
ten but that's it
okay uh what about history of tcm
treatment and or adverse reactions to
either acupuncture or herbs
there'd be no adverse reactions i did
get some acupuncture and herbs
just to manage my stress levels that was
when i was finishing my undergrad so
that's like five years ago
all right great all good thank you thank
you so how can i help you today
oh i have a headache okay when did it start
start
uh it's been going for three months now
and the issue is it just hasn't gone away
away
um it restarted gradually over a couple
of weeks
and it's been pretty constant from then
until now
okay and where is this pain located um
it's across my hole for it okay and does
it radiate to any other areas
nope just my whole head it feels pretty heavy
heavy
and tired
okay and how would you describe the
headache describe it um
i guess i just have this dull heavy pain
across my foot
my eyebrows also feel tense okay and is
it constant
or does it come and go it is present
every day
okay and do you find that the pain
varies at different times of the day
yeah um it's normally more severe just
when i wake up
um during the day it's not so bad but it
gets worse again in the afternoon
especially if i'm exhausted okay and do
you know what may have actually
caused the headache for example was it
after an illness an event
or a change in your health or your lifestyle
lifestyle
there's nothing i can think of like i
said it was three months ago so that was
the beginning of winter i'm kind of
surprised because i just began a health kick
kick
at the end of summer and i even changed
my diet to raw foods because they're healthier
healthier
right okay and have you experienced any
headaches before this
not much um i've just had a light
headache that lasted a few hours every
now and then
that's it okay and what factors
aggravate your headache to make it worse
for example certain foods
cold heat changing weather well
also after i eat which is strange
because i have salad most days
okay so is there anything that helps to
relieve the pain
oh panadol normally takes the edge off
if i'm well rested it's not so bad
either i think i need a long holiday
yes a holiday would be good uh but so
anyway you mentioned that the pain
changes in severity
so how would you rate the pain today out
of scale of zero to ten with ten being
the worst
probably a three out of ten okay
and how would you rate the pain when
it's at swiss
easily a six or seven out of ten
how about your eyes and vision have you
noticed any change
well my eyes feel heavy and tired at the
end of each day
and sometimes um my eyes are sticky just
when i wake up
okay and do they burn or do you notice a discharge
discharge
no it's nothing too bad it's just a bit sticky
sticky
when i wake up but it disappears after a
shower no pain or anything
right okay good and any symptoms related
to your ears
hearing even tinnitus i don't think so
actually what is tinnitus it's a ringing
sound in your ears
um no i don't have that i think my ears
my hearing are fine
okay great and do you experience any
nasal or sinus symptoms
now that you mention it i do have a
stuffy dripping nose
uh most mornings okay and what's the
color and consistency of the discharge
consistency um it's clear and watery
and it gets worse when it's raining like
today okay
what about the amount it's not a lot
usually i blow my nose a few times
in the morning and that's about it for
the day
do you experience any dizziness
sometimes uh in the morning again or if
i'm tired
the dizziness actually started at the
same time as my headache so it's been
going for about three months
right okay and is this dizziness that
you mentioned is it worse when you get
up quickly
from a sitting or lying down position no
um it comes and it goes it's worse when
i'm tired but
i don't think it's anything serious okay
um do you feel any stiffness or pain in
your neck or shoulders
um my shoulders are really tense a bit
sore i think it's from the stress i'm um
doing my phd at the moment and that's
obviously challenging
yes no doubt that's a huge challenge so
how do you respond to that kind of stress
stress
um it's hard no i'm always tired
headaches make it worse and then i can't concentrate
