The purpose of writing this letter is to ask for my collaboration with you in my attempt to treat in my effort to treat a patient revered from chiropractor. She is greatly affected by emotions from her current family situation, which involves divorce, and would require your counseling services to cope with her condition. Having gone through the report on the patient’s history of the condition, previous tests and treatments done on her, as well as her current progress, I decided to use Traditional Chinese Medicine (Lin et al., 2014) in the treatment of our mutual patient which is yielding good results. The patient is a 56-year-old white female whose name is TL. TL’s present illness started about 120 days ago with a feeling of pain and tightness in her shoulder and upper back. She has a medical history of seasonal allergies but she did not experience significant illnesses in her child age.
During her first visit, she was experiencing so much main that she described it as one which she has never experienced before, which she gave a rating of 9/10. The condition in aggravated by normal manual and mental work. Heat and ice treatments, as well as many sessions of massage therapy, did not offer any relief. When she visited a chiropractor four times, she was a bit relieved but the results were not steady. She tried acupuncture after recommendations by the chiropractor but the problem persisted which made her resort to pain medication. Since her pain is still unbearable, she takes 2 pills of Advil after every four hours and one 5mg Ambien before. Her daily functioning and sleep are interrupted by the pain. For three weeks now, we have been treating her three times per week with acupuncture using acupuncture w/e-stem therapy and cupping. This has greatly minimized the pain to a rate of 4/10 to 5/10. The patient has a good prognosis, where we expect her to overcome the symptoms completely in the next 3 weeks.
TL has not had gynecological diseases but has had one miscarriage in her lifetime. She had two IVF pregnancies which led to three live births with twins through C-section. She has never had transfusions, hazardous exposure, injuries, or trauma. For the history of her family, her father died of prostate cancer while her mother died of lung cancer. Bothe parents had strokes. However, it is her social history which is of more concern. She is struggling with emotions caused by a divorce with her husband, who has already acquired a new girlfriend and their firstborn son has left the family. Their home is currently on sale. Though she does not take recreational drugs or smoke, she drinks two cuts of red wine every day. But she takes healthy meals of whole organic foods, fresh fruits, and vegetables. She went through all the required child immunizations. Her cholesterol levels are normal while she has no weight changes, night sweats or fever. She has fairly good hematopoietic and integument conditions.
Her nose, ears, breasts, and mouth do not have strange conditions but her eyes are aided with glasses and had not had changes in the last two years. From the tests we have carried out, her cardiovascular, endocrine, urinary, reproductive, neural, and pulmonary systems have not been experiencing any bad symptoms but her gastrointestinal system is affected by heartburns with some types of food. In our diagnostic tests, there is no disc herniation. The pain she experiences in her upper back, right shoulder and neck cause numbness in the right arm and muscle tightness.
Our decision to use acupuncture was informed by successes in previous treatments of the same condition by other acupuncturists (Vickers et al., 2012). The patient’s prognosis is good as her pain has reduced and is heading to a level of 2/10 and I predict she will be stable in six weeks. However, due to her family situation, I expect my patient will get emotionally worse, and fall into a depression when the divorce gets finalized, the house been sold, while all children are living out of state. From a professional aspect, she will benefit from counseling sessions within your office. I would like to work for my patient together. TL trusts my professionalism and agreed to consider counseling sessions with you.
References
Lin, J. G., Chen, K. B., & Lee, Y. C. (2014). Upper Back Pain. In Acupuncture for Pain Management (pp. 241-242). Springer, New York, NY.
Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Foster, N. E., … & Acupuncture Trialists’ Collaboration, F. T. (2012). Acupuncture for chronic pain: individual patient data meta-analysis. Archives of internal medicine, 172(19), 1444-1453.