The Importance of Good History

All TCVM cases begin with obtaining a good history. In order to obtain a good history, it is helpful to have any medical records prior to the scheduled appointment. This allows the TCVM practitioner to have a general overview of the patient’s “on paper” medical history and previous diagnostic results. I find having this information in advance, allows me to spend more time at the beginning of the appointment discussing the client’s recent observations and current concerns. This type of discussion has more value for the DVM, client and patient, then having the client recall past medical history that could have simply been read from the medical record.

I typically review all medical notes from “kitten hood,” or whatever timeframe the available medical history began. I pay attention to any repeat conditions, such as chronic ear infections, chronic GI disease, ocular disease, and anxiety/phobias. Going back to the beginning of a pet’s story, allows me to sketch a timeline of what that pet’s life looked like, and find patterns that may be helpful with the current concerns. With that said, no matter what the pet’s previous history shows, treating the pet that is in front of me at that moment, is always the best approach. Although the medical history can give me clues, I try to remove any preconceptions, and be open to what the pet is telling me at the actual appointment.

Pets with Kidney Failure

For a pet with kidney failure, I would pay close attention to when the pet was first diagnosed and the clinical signs that were observed. I would familiarize myself with the blood work results, and if there were any comorbidities. Although TCVM can be helpful for pets that have no diagnostics, western diagnostics can enhance the TCVM pattern diagnosis. If a pet has clinical signs such as anorexia, soft stool, and lethargy with no western diagnostics, depending on the Tongue / Pulse & remainder of exam findings, a TCVM pattern diagnosis of Spleen Qi Deficiency could be made. Eight Gentleman would be an appropriate herbal formula to address this TCVM pattern. If that same pet had a CBC / Chemistry performed showing elevated BUN, Creatinine and SDMA, Eight Gentleman would still be appropriate to address the Spleen Qi Deficiency, but the TCVM practitioner would feel more confident also recommending an herbal formula to address a Kidney Deficiency. The more information that we have, the more accurate our TCVM pattern diagnosis will be and the better we can help our patients.

Being familiar with the recent blood work also allows us to stage the kidney disease (I, II, II, VI) and better communicate with the client disease trajectory and expectations. The conversation I would have with a client whose pet had dilute urine with a BUN 36 & Creatinine 2.0 would look different then a pet with a BUN 100 & Creatinine of 9.0. Depending on history, client observations and exam findings, I may be able to significantly help both of those pets, but the recent diagnostics values allow me to have a realistic & honest conversation with the family as a treatment plan is created. If based on history, exam findings and discussion with the client, the family elects to begin treatment, the minimum goal is to stabilize the disease & improve the patient’s quality of life. The ambitious goal is to reverse the disease.

Dr. Jeanette’s Appointments

I created a questionnaire that I have clients fill out prior to their scheduled initial consultation, in order to obtain information that can be helpful in making a TCVM pattern diagnosis. The questionnaire is a good way to begin the conversation with a family, and at the appointment I will often continue the discussion focusing on certain questions & answers. Sometimes clients do not fill the form out as completely as I would want, and so it is an opportunity at the appointment to say “I saw you answered that he/she has no temperature preference. Do you find there are certain places that he/she likes to lay inside or outside?” At the appointment I spend time on anything that I feel needs further clarification.

My appointments are in-home only, and typically last at least 90 minutes. For the first 20-30 minutes I am obtaining a solid history. I then do an exam on the patient, and often I keep this as non-invasive as possible. I am in the home by myself, and typically the patients that I am evaluating are not feeling great. I tend to get a lot of information through observation, but I always do my best to do a minimal western exam, get a good tongue & pulse and perform as much of an eastern exam as the pet will allow. I always make sure that I get the pets body, feet (or at least lower extremity) and ear temperature. I observe any ocular changes such as scleral injection or erythema, discharge, and dryness/chronic changes. In the least invasive way possible, I distinguish, if their mobility concerns are more related to stiffness, weakness, or a combination of both. I typically try to get information from the Bladder Channel, such as if there are any deep depressions or acupoint sensitivity. I do my best to get the most information that the pet is willing to give, without causing any unnecessary stress.

TCVM Diagnosis Kidney Failure

A good history and a solid western & eastern exam, allows me to be confident in my TCVM pattern diagnosis. I will use kidney failure as an example. If the patient recently had blood work that showed elevations in their kidney values, then a Kidney Deficiency must be included in the TCVM pattern diagnosis. The common TCVM patterns associated with kidney failure include Kidney Qi Deficiency, Kidney Yang Deficiency, Kidney Yin Deficiency, Kidney Jing Deficiency, or combinations of these patterns (ex. Kidney Yin & Qi Deficiency). There also may be concurrent TCVM patterns associated with a different Zang-fu organ such as Spleen Qi Deficiency. Having a complete history, current concerns, and a good western & eastern exam, gives us the most information allowing us to make an accurate TCVM pattern diagnosis. Being confident in the TCVM diagnosis, allows the appropriate herbal formula(s) to be recommended, as well as recommendations with the other TCVM treatment modalities. Acupuncture can be forgiving, but with an accurate TCVM diagnosis the most appropriate acupoints can be selected. An accurate pattern diagnosis is also highly important for food therapy. The foods recommended for a patient that is Yin Deficient are very different, then foods recommended for a patient that is Yang Deficient. In general food recommendations for geriatric pets tend to fall closer to neutral, as to avoid extremes, but there may be certain foods added for a geriatric Yin Deficient patient that would not be appropriate for a geriatric Yang Deficient patient.

Different Kidney Deficiency Patterns

Below I have included the patterns that I mentioned above, and highlighted how history & exam findings allow the correct TCVM pattern diagnosis to be made:

Kidney Qi Deficiency: This pet tends to be older. There is weakness, but the pet is not cold. They may have a poor appetite with weight loss, and tire more easily. Their tongue would be pale & wet. Their pulses would be deep & weak. An herbal formula that would be appropriate for this TCVM pattern diagnosis would be Jin Gui Shen Qi.

Kidney Yang Deficiency: This pet also has general weakness & lethargy, but unlike Kidney Qi Deficiency, this pet is cold. Yang Deficiency = Qi Deficiency + Cold signs. Typically, their extremities and lumbar spine are cold. They may have a weak urine stream with loose stool early in the morning. Their tongue would be swollen & purple. Their pulse would be deep and weak. Both Kidney QiDeficiency and Kidney Yang Deficiency may have weaker pulses on the right side. An herbal formula that would be appropriate for this TCVM pattern diagnosis would be You Gui Wan.

Kidney Yin Deficiency: This pet has hot & dry signs. Heat signs may include panting, cool-seeking behavior and heat intolerance. Dry signs may include dry hair, dry skin, or dry stool. Clinical signs may be worse in the Yin time of day, late afternoon, or evening. Their tongue would be red & dry. Their pulse would be thin and fast, and the left pulse may be weaker than the right. An herbal formula that would be appropriate for this TCVM pattern diagnosis would be Liu Wei Di Huang (Rehmannia 6). A more potent Yin Tonic would be Zuo Gui Wan (Restoring the Left).

Kidney Jing Deficiency: These pets are typically young with congenital problems. They may have poor neonatal growth, poor dentition, and numerous problems at a young age. They may also be weak, fatigue easily and have poor digestion. Kidney Jing Deficiency is usually a combination of Kidney Yin & Yang Deficiency. Their tongue may be pale or red. The pulse is weak. An herbal formula appropriate for this TCVM pattern diagnosis is Sheng Jing San (Epimedium Powder).

Combination patterns such as Kidney Qi & Yin Deficiency: These pets will have a combination of patterns, and one pattern may be dominant. If Yin Deficiency is dominant, the pet will be heat intolerant, panting and Polydipsic. The tongue may be red, and the pulses fast. If Qi Deficiency is dominant the pet may show significant weakness and have a pale tongue with a pulse that is weaker on the right. Treatment would be directed at the primary Deficiencies. For example, if Kidney Yin Deficiency was the primary TCVM pattern, Liu Wei Di Huang could be recommended, and food recommendations and acupoints selected may be focused on both Qi and Yin. If the Deficiencies are equal, then an herbal formula that tonifies Kidney Qi could be recommended for the morning, and an herbal formula that tonifies Kidney Yin could be administered in the evening.

 When supporting hospice patients, it can be helpful to consider the following quote. “ is more important to know what sort of person has a disease, than to know what sort of disease a person has.” This quote supports the importance of a good history & discussion with the family, as well as obtaining a solid exam.  “We will be able to help each patient better if we know who they are as an individual and remain open & listen to what they are telling us” ~ Dr. Jeanette