Case Study Report Outline

Case Study Report Outline

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Email *
example@example.com
1. ATTESTATION STATEMENT
I (clinician) confirm each of the following: 1. the information provided here accurately reflects the course of care and outcomes for the case; 2. All identifying information has been removed 3. by supplying this information, I confirm that based on my office policies, or communication with the patient whose data is provided here, I have consent to supply this information without identifiers. *

I agree
2. CLINICIAN INFORMATION
In what country do you practice ? *
What type of herbal training did you complete? *
How many years have you been practicing Chinese herbal medicine? *
Do you hold any registration or licensure to practice to Chinese herbal medicine? *

NCCAOM state licensure national registration national licensure
Where did you receive your herbal medicine training *
Do you have specific mentors for Chinese herbology? Please list.
Do you identify with any of the following paradigms when practicing Chinese herbal medicine?

Shang Han Lun Wen Bing Zang Fu modern Chinese herbal medicine (e.g. including use of herbs as antivirals) Kampo
Approximately how many acute infectious disease patients have you treated this year? *
3. PATIENT DEMOGRAPHICS
Brief Patient Description
e.g. 39 y.o. female publicist, history of asthma (Must remain the same in each entry for this patient)
Treatment/s *
Age *
Gender *
Pregnant? *
Race *

American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White Unknown or Not reported
Ethnicity *
Comorbidities *

Hypertension (controlled) Hypertension (uncontrolled) Type 2 diabetes (controlled) Type 2 diabetes (uncontrolled) Coronary disease; Congestive heart failure Other CVD COPD (non-asthma) COPD (asthma) Auto-immune or other inflammatory condition Cancer None known
Medical History, current or past *

History of lung problems, including pneumonia, asthma, COPD, or recent cold/flu, or other lung diseases History of heart problems, such as high or low blood pressure, diagnosed heart disease, angina, heart surgery, arrhythmia, atrial fibrillation (“a fib”), plaque in your arteries, high cholesterol, History of diabetes, whether Type 1 or type 2, metabolic syndrome History of digestive problems such as diarrhea, constipation, IBS, or other digestive disease None known
Pharmaceuticals *

Prescription anti-virals, (choloriquine) Prescription anti-viral (non-choloriquine) Anti-hypertention (ACEI) Anti-hypertention (non-ACEI) Lipid-lowering medications Other cardiovascular medications Corticosteriods (oral) Corticosteroids (topical) NSAIDS; Acetaminophen Antibiotics Anti-asthma medications Other immunosuppressant medications Cancer treatment/chemotherapy Cancer treatment/radiation Cancer treatment/other Other prescription medications Unknown None
Does the patient have...

Smoking history Vaping history Insufficient financial resources to cover basic necessities
Covid-19 Status (at time of treatment)

Tested positive Tested negative Suspected due to symptoms Suspected due to exposure Not known not applicable/supportive care
4. THERAPEUTIC GOAL
Therapeutic goal
5. PATIENT SYMPTOM DATA:
5A - POTENTIALY C19 RELATED
Patient chief concern
Fever, if any
Sweat, if any

Light Profuse Spontaneous (daytime) Nighttime Hands/feet and chest Oily on forehead One-sided None

Fatigue *

	1	2	3	4

1 is not at all, 4 is exhausted

Cough *

Dry Clear, thin phlegm White phlegm Yellow, thin phlegm Yellow, thick phlegm Blood-tinged phlegm None known

Shortness of breath *

	1	2	3	4

1 is not at all, 4 is severe

Chest tightness *

	1	2	3	4

1 is not at all, 4 is severe

Is patient able to take a deep breath? *
Unusual feeling in throat (weird, tight, sore, etc.)? *
Eye discharge (more than usual)? *
Diarrhea? *
Abdominal pain? *
Changes in how food tastes or smells? *
Other, potentially Covid-19 related symptoms
5B - 10 QUESTIONS (as applicable)
Headache Location
Headache Quality

Severe Dull Chronic Distending/throbbing Boring or stabbing Worse with recent illness
Eye symptoms (other than discharge, above)

Pain Swelling Redness Blurry vision/'floaters' Dryness
Ear symptoms

Tinnitus Hearing loss
Pain location
Pain quality

Constant Irregular Sharp Dull Better with pressure Worse with fatigue
Urination, stool, digestion

Nocturia Frequent daytime Urination Urgency Inhibited urination Lack of urination BM less than daily Constipation Diarrhea Loose stools Acid reflux Bloating Belching Stomach pain
Thirst, appetite

Lack of appetite in AM Distended abdomen Excessive thirst
Sleep

Difficulty falling asleep Wakefulness Insufficient sleep more than occasionally Wake not feeling refreshed
5C OBSERVATION
Tongue body

Black spots Cracks Deviated Dusky Enlarged Flabby Long Pale Peeled Quivering Red Red sides Red spots Red tip Rough texture Scallops Scarlet Small Sores on tongue Stiff Swollen Tender texture Thick tongue body Thin tongue body White spots
Tongue coat

Thick Thin Little coat No coat Geographic/patchy White Yellow Gray Black Dry Greasy Moist / wet No root
6. DIAGNOSIS DATA
Primary Theoretical Paradigm selected for this case *

Shang Han Lun Wen Bing Zang Fu Modern Chinese herbal medicine (e.g. including use of herbs as antivirals) Kampo None
Reasoning for theoretic paradigm selected
if applicable
Key Diagnostic points *
7. DETAILS OF FORMULA
Base Formula

Bai Hu Tang Ban Xia Hou Po Tang Chi Ge Jie Ji Tang Chai Hu Gui Zhi Tang Da Yuan Yin Er Chen Tang Gan Lu Xiao du Yin Ge Gen Tang Gui Zhi Tang Hou Po Xia Ling Tang Huo Xiang Zheng Qi San Ling Gui Zhu Gan Tang Ma Huang Tang Ma Xing Shi Gan Tang Mai Men Dong Tang Qing Fei pai du yin San Ren Tang Sang Ju Yin Sha Shen Mai Dong Tang She Ga Ma Huang Tang Sheng Mai San Wei Jing Tang Wu Ling San Xiao Chai Hu Tang Xiao Xian Xiong Tang
Secondary Formula

Bai Hu Tang Ban Xia Hou Po Tang Chi Ge Jie Ji Tang Chai Hu Gui Zhi Tang Da Yuan Yin Er Chen Tang Gan Lu Xiao du Yin Ge Gen Tang Gui Zhi Tang Hou Po Xia Ling Tang Huo Xiang Zheng Qi San Ling Gui Zhu Gan Tang Ma Huang Tang Ma Xing Shi Gan Tang Mai Men Dong Tang Qing Fei pai du yin San Ren Tang Sang Ju Yin Sha Shen Mai Dong Tang She Ga Ma Huang Tang Sheng Mai San Wei Jing Tang Wu Ling San Xiao Chai Hu Tang Xiao Xian Xiong Tang
If no base formula used, individual formula written

Bai Dou Kou Bai He , Lilii Bulbus Bai Shao , Paeoniae Radix Alba Bai Zhu , Atractylodis Macrocephalae Rhizoma Ban Len Gen , Isatidis Root , Isatis root Ban Xia , Pinelliae Rhizoma , Pinellia Bo He , Menthae haplocalycis Herbs , Mentha, field mint Chai Hu , Bupleuri Radix, Buplerum, hare's ear root Chuan Bei Mu , Fritillariae Cirrhosae Bulbus , Sichuan fritillaria bulb Chuan Xiong , Radix Ligustici Chuanxiong Da Huang , Rhei Radix et Rhizoma , Rhubarb Da Qing Ye, Isatidis Folium , Isatis leaf Dan Dou Chi , Sojae Semen preparatum , Prepared soybean Dan Shen , Radix Salviae Miltiorrhizae , Salvia root Dan Zhu Ye Dang Gui , Angelicae Sinensis Radix Dang Shen , Codoopsis Radix Fang Feng , Saposhnikoviae Radix , Ledebouriella root, Siler Fu Ling , Poria , Poria / hoelen Fu Zi , Aconiti Radix Lateralis Praeparata Ge Gen , Puerariae Radix , Kudzu root, peuraria Gua Lou , Trichonsanthis Fructus Gui Zhi , Cinnamomi Ramulus , Cinnamon Twig Cassia Twig Hou Po , Cortex Magnoliae Officinalis Huang Bai , Phellodendri Cortex Huang Lian , Coptidis Rhizome , Coptis / Goldthread rhizome Huang Qi , Astragali Radix Huang Qin , Scutellaria Radix , Skullcap root / scute Huo Xiang , herba Pogostemi seu Agastaces Jie Geng , Platycodonis Radix , Platycodon root / Balloonflower root Jin Yin Hua , Lonicerae Flos , Honeysuckle Jing Jie , Schizonepetae Herba, kuan dong hua Lian Qiao , Forsythiae Fructus , Forsythia fruit Ma Huang , Ephedrae Herba , Ephedra Mai Men Dong , Ophiopogonis Radix Pi Pa Ye , Eriobotryae Folium Qiang Huo , Notopterygii Rhizoma seu Radix Qing Hao , Artemisiae Annuae Herba Ren Shen , Ginseng Radix Sang Ye , Mori Folium , White mulberry leaf Sha Shen , Glehniae/Adeophoeae Radix She Gan , Belamcandae Rhizoma , Belamcanda Sheng Di Huang , Rehamnniae Radix , Dried Chinese foxglove root Shi Gao , Gypsum fibrosum Shi Hu , Dendrobii Herba Tao Ren , Semen Persicae Tian Hua Fen , Trichosanthis Radix , Trichosanthes root Wu Wei Zi , Schisandrae Fructus Wu Zhu Yu , Evodiae Fructus Xi Yang Shen , Panacis Quinquefolii Radix Xin Yi Hua , Magnoliae Flos , Magnolia flower Xing Ren , Armeniacae Semen , Bitter Apricot Kernel Yi Yi Ren , Coicis Semen , Coix seed / Job's tears Ze Xie , Alismatis Rhizoma Zhi Mu , Anemarrheanae Rhizoma Zhi Shi , Fructus Immaturus Citri aurantii , Unripe bitter orange Zhi Zi , Gardeniae Fructus , Gardenia fruit Zhu Ling , Polyporus Zhu Ru , Bambusae Caulis in Taenia Zi Su Ye , Perillae Folium Zi Wan , Asteris Radix
Substances added to base formula

Bai Dou Kou Bai He , Lilii Bulbus Bai Shao , Paeoniae Radix Alba Bai Zhu , Atractylodis Macrocephalae Rhizoma Ban Len Gen , Isatidis Root , Isatis root Ban Xia , Pinelliae Rhizoma , Pinellia Bo He , Menthae haplocalycis Herbs , Mentha, field mint Chai Hu , Bupleuri Radix, Buplerum, hare's ear root Chuan Bei Mu , Fritillariae Cirrhosae Bulbus , Sichuan fritillaria bulb Chuan Xiong , Radix Ligustici Chuanxiong Da Huang , Rhei Radix et Rhizoma , Rhubarb Da Qing Ye, Isatidis Folium , Isatis leaf Dan Dou Chi , Sojae Semen preparatum , Prepared soybean Dan Shen , Radix Salviae Miltiorrhizae , Salvia root Dan Zhu Ye Dang Gui , Angelicae Sinensis Radix Dang Shen , Codoopsis Radix Fang Feng , Saposhnikoviae Radix , Ledebouriella root, Siler Fu Ling , Poria , Poria / hoelen Fu Zi , Aconiti Radix Lateralis Praeparata Ge Gen , Puerariae Radix , Kudzu root , peuraria " Gua Lou , Trichonsanthis Fructus Gui Zhi , Cinnamomi Ramulus , Cinnamon Twig Cassia Twig Hou Po , Cortex Magnoliae Officinalis Huang Bai , Phellodendri Cortex Huang Lian , Coptidis Rhizome , Coptis / Goldthread rhizome Huang Qi , Astragali Radix Huang Qin , Scutellaria Radix , Skullcap root / scute Huo Xiang , herba Pogostemi seu Agastaces Jie Geng , Platycodonis Radix , Platycodon root / Balloonflower root Jin Yin Hua , Lonicerae Flos , Honeysuckle Jing Jie , Schizonepetae Herba, kuan dong hua Lian Qiao , Forsythiae Fructus , Forsythia fruit Ma Huang , Ephedrae Herba , Ephedra Mai Men Dong , Ophiopogonis Radix Pi Pa Ye , Eriobotryae Folium Qiang Huo , Notopterygii Rhizoma seu Radix Qing Hao , Artemisiae Annuae Herba Ren Shen , Ginseng Radix, Sang Ye , Mori Folium , White mulberry leaf Sha Shen , Glehniae/Adeophoeae Radix She Gan , Belamcandae Rhizoma , Belamcanda Sheng Di Huang , Rehamnniae Radix , Dried Chinese foxglove root Shi Gao , Gypsum fibrosum Shi Hu , Dendrobii Herba Tao Ren , Semen Persicae Tian Hua Fen , Trichosanthis Radix , Trichosanthes root Wu Wei Zi , Schisandrae Fructus Wu Zhu Yu , Evodiae Fructus Xi Yang Shen , Panacis Quinquefolii Radix Xin Yi Hua , Magnoliae Flos , Magnolia flower Xing Ren , Armeniacae Semen , Bitter Apricot Kernel Yi Yi Ren , Coicis Semen , Coix seed / Job's tears Ze Xie , Alismatis Rhizoma Zhi Mu , Anemarrheanae Rhizoma Zhi Shi , Fructus Immaturus Citri aurantii , Unripe bitter orange Zhi Zi , Gardeniae Fructus , Gardenia fruit Zhu Ling , Polyporus Zhu Ru , Bambusae Caulis in Taenia Zi Su Ye , Perillae Folium Zi Wan , Asteris Radix
Substances subtracted from base formula

Bai Dou Kou Bai He , Lilii Bulbus Bai Shao , Paeoniae Radix Alba Bai Zhu , Atractylodis Macrocephalae Rhizoma Ban Len Gen , Isatidis Root , Isatis root Ban Xia , Pinelliae Rhizoma , Pinellia Bo He , Menthae haplocalycis Herbs , Mentha, field mint Chai Hu , Bupleuri Radix, Buplerum, hare's ear root Chuan Bei Mu , Fritillariae Cirrhosae Bulbus , Sichuan fritillaria bulb Chuan Xiong , Radix Ligustici Chuanxiong Da Huang , Rhei Radix et Rhizoma , Rhubarb Da Qing Ye, Isatidis Folium , Isatis leaf Dan Dou Chi , Sojae Semen preparatum , Prepared soybean Dan Shen , Radix Salviae Miltiorrhizae , Salvia root Dan Zhu Ye Dang Gui , Angelicae Sinensis Radix Dang Shen , Codoopsis Radix Fang Feng , Saposhnikoviae Radix , Ledebouriella root, Siler Fu Ling , Poria , Poria / hoelen Fu Zi , Aconiti Radix Lateralis Praeparata Ge Gen , Puerariae Radix , Kudzu root , peuraria " Gua Lou , Trichonsanthis Fructus Gui Zhi , Cinnamomi Ramulus , Cinnamon Twig Cassia Twig Hou Po , Cortex Magnoliae Officinalis Huang Bai , Phellodendri Cortex Huang Lian , Coptidis Rhizome , Coptis / Goldthread rhizome Huang Qi , Astragali Radix Huang Qin , Scutellaria Radix , Skullcap root / scute Huo Xiang , herba Pogostemi seu Agastaces Jie Geng , Platycodonis Radix , Platycodon root / Balloonflower root Jin Yin Hua , Lonicerae Flos , Honeysuckle Jing Jie , Schizonepetae Herba, kuan dong hua Lian Qiao , Forsythiae Fructus , Forsythia fruit Ma Huang , Ephedrae Herba , Ephedra Mai Men Dong , Ophiopogonis Radix Pi Pa Ye , Eriobotryae Folium Qiang Huo , Notopterygii Rhizoma seu Radix Qing Hao , Artemisiae Annuae Herba Ren Shen , Ginseng Radix, Sang Ye , Mori Folium , White mulberry leaf Sha Shen , Glehniae/Adeophoeae Radix She Gan , Belamcandae Rhizoma , Belamcanda Sheng Di Huang , Rehamnniae Radix , Dried Chinese foxglove root Shi Gao , Gypsum fibrosum Shi Hu , Dendrobii Herba Tao Ren , Semen Persicae Tian Hua Fen , Trichosanthis Radix , Trichosanthes root Wu Wei Zi , Schisandrae Fructus Wu Zhu Yu , Evodiae Fructus Xi Yang Shen , Panacis Quinquefolii Radix Xin Yi Hua , Magnoliae Flos , Magnolia flower Xing Ren , Armeniacae Semen , Bitter Apricot Kernel Yi Yi Ren , Coicis Semen , Coix seed / Job's tears Ze Xie , Alismatis Rhizoma Zhi Mu , Anemarrheanae Rhizoma Zhi Shi , Fructus Immaturus Citri aurantii , Unripe bitter orange Zhi Zi , Gardeniae Fructus , Gardenia fruit Zhu Ling , Polyporus Zhu Ru , Bambusae Caulis in Taenia Zi Su Ye , Perillae Folium Zi Wan , Asteris Radix
Notes on relative dosage of substances if applicable
Method of administration

Raw Vacuum pack Granule Tincture
Number of grams/day of granules

1-10 11-20 21-30 31-40 41-50 51-60 61-80 More than 80

Number of packets/day (raw)

	1	2	3	4	5	6	7

1 is , 7 is

Other notes on formula
8. TREATMENT REGIMEN
At what point in disease process was this treatment administered *

Prevention Early Symptoms Mid Symptoms Late Symptoms Recovery

Days formula taken *

	1	2	3	4	5	6	7

1 is , 7 is

Response at 24 hours
Response at 48 hours
Response at 72 hours
Notes on treatment response *
Please provide any additional details about the patient/client's trajectory of care, including your clinical impressions of how useful your care may have been.
9. OTHER COMPONENTS OF TREATMENT
Setting and context of treatment *
Other treatment received from you *

Acupuncture Acupressure Moxibustion Cupping Exercises Qi Gong Tui Na Tai Ji Lifestyle Advice None
Treatment received from other providers *

Acupuncture Acupressure Moxibustion Cupping Exercises Qi Gong Tui Na Tai Ji Lifestyle Advice None known
10. OUTCOMES
Common/possible side effects of herbal therapy *

GI upset Headache Sweating None
Patient chief concern
Fever, if any

Below 99 but feeling hot or elevated for this patient 99-100.4 (37-38) 100.5-102.2 (38-39) above 102.2 (39)
Sweat, if any

Light Profuse Spontaneous (daytime) Nighttime Hands/feet and chest Oily on forehead None

Fatigue

	1	2	3	4

1 is Not at all, 4 is Severe

Cough

Dry Clear, thin phlegm White phlegm Yellow, thin phlegm Yellow, thick phlegm Blood-tinged phlegm None

Shortness of breath

	1	2	3	4

1 is Not at all, 4 is Severe

Chest tightness

	1	2	3	4

1 is Not at all, 4 is Severe

Are you able to take a deep breath?

Yes No Not assessed
Unusual feeling in throat (weird, tight, sore, etc.)?

Yes No Not assessed
Eye discharge (more than usual)?

Yes No Not assessed
Diarrhea?

Yes No Not assessed
Abdominal pain?

Yes No Not assessed
Changes in how food tastes or smells?

Yes No Not assessed
Other, potentially Covid-19 related symptoms
Overall case outcome: *

Not infected with COVID Full recovery remained outpatient Partial recovery remained outpatient, hospitalization ICU hospitalization other Death Patient remains under care/outcomes to be added later
GENERAL COMMENTS
General Comments *
Please let us know if this tool will be useful for you and if it responds to your case study reporting needs:
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Case Study Report Outline

1. ATTESTATION STATEMENT

2. CLINICIAN INFORMATION

3. PATIENT DEMOGRAPHICS

4. THERAPEUTIC GOAL

5. PATIENT SYMPTOM DATA:

5A - POTENTIALY C19 RELATED

5B - 10 QUESTIONS (as applicable)

5C OBSERVATION

6. DIAGNOSIS DATA

7. DETAILS OF FORMULA

8. TREATMENT REGIMEN

9. OTHER COMPONENTS OF TREATMENT

10. OUTCOMES

GENERAL COMMENTS