Consultation Report
Consultation reports are commonly written to physicians or other health care practitioners who have referred patients to other specialists. While it is as yet uncommon for MDs to ask for consultations with acupuncturists, it is not uncommon for one acupuncturist to as for the diagnosis or advice of another acupuncturist. Although the two acupuncturists may be close friends, a written consultation report should still be sent to the referring practitioner as a formal record of the consultation which is then included in the patient’s medical records.
Sample consultation report:
Patient name: Jane E. Pregnant
Age/sex: 29 year-old female
Consultant: R.E.W.., Lic. Ac.
Attending practitioner: C.W.C., Lic. Ac.
Reason for consult: Evaluate pattern discrim.
Thank you for asking me to see this 29 year-old pregnant female who is suffering from severe nausea and vomiting during pregnancy. Having gone over this patient’s history and examined her according to the four examinations, it is my opinion that continued vomiting has damaged the patient’s stomach fluids. Therefore, I believe her CM pattern discrimination is: liver-stomach disharmony with depressive heat and ceaseless vomiting damaging stomach fluids. If this pattern discrimination is correct, then the treatment principles I suggest are to: harmonize the liver and stomach, resolve depression and clear heat, engender fluids and downbear counterflow.
Suggested Tx plan:
Acupuncture daily for 3-5 days, 30 minute retention
Points needled: Zu San Li (St 36), Nei Guan (Per 6), Zhong Wan (CV 12), Tai Chong (Liv 3),
Xing Jian (Liv 2), Nei Ting (ST 44)
CM Rx: Xiao Chai Hu Tang Jia Wei (Minor Bupleurum Decoction with Added Flavors)
Radix Bupleuri (Chai Hu), 10g
Radix Scutellariae Baicalensis (Huang Qin), 10g
Rhizoma Pinelliae Ternatae (Ban Xia), 10g
Radix Codonopsitis Pilosulae (Dang Shen), 10g
Tuber Ophiopogonis Japonici (Mai Men Dong), 10g
Rhizoma Phragmitis Communis (Lu Gen), 10g
Caulis Bambusae In Taeniis (Zhu Ru), 10g
Fructus Citri Sacrodactylis (Fo Shou), 6g
mix-fried Radix Glycyrrhizae (Gan Cao), 6g
uncooked Rhizoma Zingiberis (Sheng Jiang), 2 slices
Fructus Zizyphi Jujubae (Da Zao), 3 pieces
1 packet per day decocted in water and administered in 3 divided doses
If you would like to discuss this case further with me, please do not hesitate to call, and thanks again for the opportunity of consulting on this patient.
Yours sincerely,
R.E.W., Lic. Ac.
T: 11-29-01