Case studies are very common for acupuncture school students, either in class exams or during taking the national board exam. Most test takers feel they have no idea where they should start and how they should start to analyze those complicated cases. Sometimes, they get totally lost and feel very frustrated. The worst part is that case studies always account for a big percentage in the board exam. In the Board exam of Foundations of Oriental Medicine, 60% to 70% or more are case study questions. Therefore, how strong we are in analyzing cases will determine whether we can pass the exam or not. I would like to share a method on how to analyze Chinese medicine case studies more effectively and efficiently. By doing plenty of practice questions with this method, you will feel more confident in passing the exam or even when seeing patients.
In 2011, one of my Chinese students asked me about the national licensing board exam when she started to prepare for them in acupuncture school. She said, “Dr. Li, I need your help because my English is very poor. It takes me so long to read a long case question. Sometimes, I do not even know some words in the question. I worry this will affect my understanding of the question and I may use up the test time. What should I do?” I asked her if she knew most of the words in the question and she said yes. I then asked if she had a strong foundation in TCM and she said “not bad.” I told her it wouldn’t be a problem if she followed my method to prepare for the case study questions. She seemed to be a little bit doubtful at the beginning, but still followed this method to do plenty of practice case questions. Three months later, she was the first student to pass the foundations module exam in her class. From her successful experience, I decided to rethink this method and started to apply it in my future board review classes. If a person who has poor English with a certain knowledge of foundations of TCM can pass the exam, there is no excuse for students who speak native English with a strong foundation of TCM to fail the exam. I always believe the students who pass the board exam study hard and put a lot of effort, all the time. Nothing can replace their effort in preparing for the exam. Even the best or most efficient test-taking tips or methods in the world cannot replace their daily reading and the foundation that they are building. Finally, I have a few key words in my mind that may be the answer for the questions in the first paragraph. The key words are, having a strong foundation and knowledge, efficient tools and a method.
The Foundation board exam has different types of case studies, such as Zang-Fu Pattern differentiation, Treatment Plan Case Study, Four Levels (Wei, Qi, Ying, Xue) Pattern/Syndrome Differentiation, Six Stages (Liu Jing) Pattern/Syndrome Differentiation, Five Elements (Wu Xing) Pattern/Syndrome Differentiation, Root and Branch Case Study. Here, I will only introduce Zang-Fu Pattern differentiation as an example.
The method can be applied by three steps:
- First tongue and pulse diagnosis to rule out distracted or wrong options.
- Combined systemic symptoms of different organs to confirm the option.
- Run deductive reasoning to reconfirm the final option.
Let’s take a case to apply this method. A patient has slight premenstrual tension with depression and weeping. She has breast and abdominal distention, tiredness, sore back, feeling cold, frequent and pale urination, and low sex drive. The tongue is pale and swollen. The pulse is deep and weak. What is the pattern?
A. Liver Blood Deficiency
B. Spleen and Kidney Yang Deficiency
C. Stagnant Liver Qi attacking Spleen
D. Kidney Qi Deficiency
Tongue and pulse diagnosis first to rule out distracted or wrong options. Pale and swollen tongue = Yang deficiency (cold-dampness accumulation). Deep and weak pulse = Yang deficiency (particular Kidney deficiency). A deficient tongue and pulse suggests a deficient pattern. Therefore, we can rule out C (Stagnant Liver Qi attacking Spleen) because stagnant Liver Qi belongs to an excess pattern. The pulse is not wiry. It is not Liver disorder. We can rule out A (Liver Blood Deficiency). Now, only options B and D are left.
Combined systemic symptoms of different organs to confirm the option. Slight pre-menstrual tension with depression and weeping = Qi stagnation (caused by cold). Breast and abdominal distention = Qi stagnation (caused by cold). Tiredness = Qi deficiency. Sore back, feeling cold, frequent and pale urination, and low sex drive = Kidney Yang deficiency. Pale and swollen tongue = Yang deficiency (cold-dampness accumulation). Deep and weak pulse = Yang deficiency (particular Kidney deficiency).
Note: Qi deficiency will cause body weakness. The body will feel tiredness. While Yang deficiency will lead to deficient cold. Cold tends to contract the qi circulation, which results in qi stagnation marked by pain such as tension (cramping), depression and weeping before period. If the cold contracts the Spleen channel, will cause abdominal pain. If the cold contracts the Kidney channel, will cause lower back soreness. Therefore, we can rule out D (Kidney qi Deficiency). Only B (Spleen and Kidney Yang Deficiency) are left.
Run deductive reasoning to reconfirm the final option. Spleen and Kidney Yang Deficiency = slight pre-menstrual tension with depression and weeping = breast and abdominal distention = tiredness = sore back, feeling cold, frequent and pale urination, and low sex drive = pale and swollen tongue, deep and weak pulse. It all makes sense, so we’re pretty sure the answer is B (Spleen and Kidney Yang Deficiency).