Clinical Case #1
History and Symptoms
The patient experienced a workplace accident when a falling object from the second floor struck them, causing them to faint. They were promptly sent to the hospital for treatment, where skin injuries on the head were discovered along with aching pain. Appropriate treatment was administered. However, two weeks later, the patient began experiencing prickling pain on the right side of their head, with three or four attacks per day that worsened at night.
To diagnose the patient's chief complaint of headache, a total of nine syndromes should be considered (link to headaches). Symptoms in boldface should be compared against those listed under each of the nine syndromes. The patient's symptoms in boldface are found under "9. Blood coagulation syndrome." Therefore, the diagnosis is as follows:
- Wind-cold syndrome (o) - None
- Wind-heat syndrome (o) - None
- Wind-dampness syndrome (o) - None
- Liver yang upsurging syndrome (o) - None
- Dampness-sputum syndrome (o) - None
- Energy deficiency syndrome (o) - None
- Blood deficiency syndrome (o) - None
- Kidney energy deficiency syndrome (o) - None
- Blood coagulation syndrome (5) - Headache caused by external injuries, with prickling pain in the head (1).
The diagnosis with the highest score of 5 is 9. Blood coagulation syndrome.