The following Exemplar Answer has been deconstructed into sections to assist in explaining what is

required from each element of the answer. Comment boxes on the side give further clues as to how
to approach the answer.

Case Details
Pale and lustreless complexion: Lung deficiency >>> Blood deficiency (?) >>>Yin Deficiency (?)

Comment [u1]: Look for commonalities

Light sweating during day: Lung deficiency >>> Yin Deficiency (?) >>> Exterior cold with Ying/Wei
disharmony (?)
Low spirits: Lung deficiency (grief/sadness/melancholy associated with lungs; lung qi deficiency =
Gloomy mind) >>> Blood deficiency (blood houses/nourishes shen) (?) >>> Yin Deficiency (?)
Dry Hair: Kidney deficiency >>> Blood Deficiency (?) >>> Yin Deficiency (?) >>> Lung qi deficiency
(fluid distribution) (?)
Headache: Large intestine channel >>> Liver excess >>> Blood deficiency >>> could be anything
Poor Appetite: Spleen deficiency >>> Cold in middle jiao (?) >>> Liver constraining Spleen (?)
Worry: Spleen deficiency >>> Lung Deficiency (if associated with sadness)(?)
Thin : distractor could be a multitude of things including simple constitution

Comment [u5]: Avoid distractors and

look for the most common and frequent
relationship

Lung qi deficiency with secondary spleen qi deficiency

Comment [u6]: Only one student did a
five element approach so I am providing a
sample answer that matches the majority
of data presented

Using a Zhang Fu approach the following diagnosis applies:

The primary diagnosis is Lung Qi Deficiency.
There is a secondary spleen qi deficiency.
There are always other possibilities but take into account

Comment [u3]: These signs coloured in

purple are important if using a 5 element
diagnosis/treatment because they
establish an excess of energy in the wood
element (yin deficiency leading to excess
liver yang)
Comment [u4]: Spleen and blood
deficiency possibly related

Diagnosis 1 mark

Comment [u2]: Possible link to Lungs

The most commonly occurring relationships

Avoid minor indications that sit outside of the primary pattern and act as distractors
Look for inter-relationships between potential pathologies and related processes
Listen to clues I did mention to study Lung and Large intestine channels and 5 elements.
This could have resulted in the alternative approach detailed later in the document.

Page 1 of 7

Quick and Dirty Justification 5 marks

The primary diagnosis is Lung Qi deficiency. This is evidenced by the following signs and symptoms:

pale and lustreless complexion pale complexions can also relate to blood deficiency but
the lustreless nature or ashen type characteristic is more commonly associated with lung
deficiencies.
Light sweating during the day this can relate to lung deficiency, yin deficiency or be
associated with an exterior cold or heat attack. The time of day excludes a yin pathology
and there were a lack of corroborating symptoms that suggested exterior attack and hence
the most likely pathology is one of lung qi deficiency not controlling the pores resulting in
subsequent sweating
o Low spirits and worry can be associated with a number of pathologies including
those affecting the lung, blood, spleen and heart. Given the overall combination of
symptoms and predominance of other lung signs, it is likely that the low spirits and
worry are associated with a lung qi deficiency. The lungs are most commonly
associated with grief and sadness and a melancholic state of mind.
o Low spirits and worry can be associated with a number of pathologies including
those affecting the lung, blood, spleen and heart. Given the overall combination of
symptoms and mixed pathology, it is likely that the low spirits and worry are
associated with a spleen qi deficiency. The spleen qi deficiency would result in a
blood deficiency as the spleen is responsible for manufacture of the blood. As the
blood houses the Shen, it is possible that the deficiency in blood would generate low
spirits which could lead to worry and further exacerbation of the mental state.
o You might try and argue that the blood deficiency then leads to a heart deficiency
however where are the corroborating heart signs and symptoms? If they arent any
or there arent enough of them then this is not a likely pathology. Hence, while you
might get some marks if your logic is sound I would not accept this as an
appropriate answer and full marks would not be awarded.

Comment [u7]: The exemplar is more

reflective of what would be required in an
exam situation rather than a quick and
dirty justification. Your mark from the
exercise reflects a lower requirement than
the example provided here.

Comment [u8]: You can easily mount

an alternative and acceptable argument as
noted in the second dot point. This is
acceptable because it fits the overall
symptom pattern as a reasonable
possibility. The third dot point does not fit
the symptom picture well and would be
marked down substantially.

Comment [u9]: This does not logically

sit with the majority of evidence so the
proposition should be rejected

A secondary pathology of spleen qi deficiency is evidenced by the following symptoms:

Poor appetite the spleen is responsible for the transformation of food and fluids. Where
the spleen becomes deficient and is unable to perform this basic function, a loss of appetite
can occur.
Low spirits and worry can be associated with a number of pathologies including those
affecting the lung, blood, spleen and heart. Given the overall combination of symptoms and
mixed pathology, it is likely that the low spirits and worry are associated with a spleen qi
deficiency. The spleen qi deficiency would result in a blood deficiency as the spleen is
responsible for manufacture of the blood. As the blood houses the Shen, it is possible that
the deficiency in blood would generate low spirits which could lead to worry and further
exacerbation of the mental state.

Page 2 of 7

Comment [u10]: You can use the dot

point from above to justify the spleen
disorder

Additional pointers
This is a quick and dirty example so I am not covering all items.

you can mount an argument about the dry hair and relate it to the lungs or the spleen blood
deficiency
you can make a link between the headache and lungs via the large intestine channel
you can start to place the diagnosis in the context of a Tai Yin (lung and spleen) connection
and disharmony
You should be attempting to draw together the most likely pathology scenario that explains
the symptoms as a best fit. As such you need to identify and address the key symptoms and
make effective judgements about which symptoms are not key to the diagnosis.

Alternative Proposition
If you were to place this diagnosis within the construct of a 5 element, movement of energy
treatment you would need to establish where the deficiencies lie, which deficiency is the largest (in
this case the lung) and where the excess lies (in this case the Liver). The diagnosis would be
modified accordingly: (liver excess/lung deficiency)
An excess of liver qi can be established by the following symptoms:
Headache: there is a possibility of Liver yang rising which is resulting in the patient experiencing
headaches. Given that the blood deficiency signs could result in a lack of yin, then there is a
tendency for the liver yang to rise in these scenarios. Depression is commonly associated with liver
qi stagnation and the poor appetite could result from a liver disharmony affecting the earth (spleen).
If this argument is fleshed out, clearly establishing an excess of energy in the liver and a deficiency of
energy in the lung, then in terms of movement of energy, this would result in treatment via the ke
cycle, taking energy through the spleen (addressing those symptoms) and thereby balancing all
organs. This would determine which points would be used for treatment. However, in the
discussion of that treatment, the secondary (non-system related) effects of the points should also be
discussed, not just the command point relationships for moving the energy.

Page 3 of 7

Comment [u11]: As the majority of

students did not answer the question from
a 5 element perspective, I will not discuss
this further as it is not relevant to the
outcome of the exercise.

Treatment Principle 1 mark

Tonify the Lungs deficiency and support the spleen (or words to this effect)

Treatment protocol
Provide an acupuncture treatment protocol for this patient. Give an explanation of the process by
which you chose your protocol, why the points selected were chosen, account for their synergistic
effects. Explain any relevant needle techniques - why you would use them and how would they
change the treatment outcome. Explain what additional modality/technique you would apply why
and how it would modify the treatment outcome.

Comment [u12]: Key words are

highlighted. You can easily break this
question into component parts

If you scored poorly in this section there were two primary reasons
1. you simply did not address the primary aspects of the question noted above
2. you assumed that a simple description of point function constitutes the explanation of a
treatment protocol
This is an open book exam. It is going to test your thinking and creative application of knowledge to
a problem. If the only information you provide is what I can read in any reference book, then you
will not achieve the desired learning outcome.

Provide an explanation of the process for choosing your protocol (why points were chosen)
If you choose to treat via a system e.g. 5 elements your justification would be that you have:

identified a clear disharmony between two elements.

clearly linked this back to your diagnosis and the pattern of symptom presentation. This
constitutes your explanation.
made a judgment call that an alternative system of treatment is less suitable.
The pattern for qi and blood disruption and more importantly the treatment of that
disruption fits the model of treatment that you have chosen. This also makes up part of your
explanation of why you chose 5 elements to treat.

It appeared from the surface that most students adopted a simple approach of symptomatics. In
other words, there was a random selection of points one to treat each presenting symptom. If this
is the approach that you took, then the justification would be something like:
The symptoms presented formed a simple unrelated pattern where most the presenting signs were
relating to the lung channel or spleen organ. As there appeared to be no underlying pattern of
pathology which linked the signs and symptoms a simple approach of symptomatic treatment was
chosen. Hence a single point for each of the major symptoms is presented.
Page 4 of 7

Comment [u13]: Goodness of fit to the

model of 5 elements

Comment [u14]: Another goodness of

fit test

Comment [u15]: The underlying

assumption is that one of the different
treatment models fits particular patterns of
disease better than another model. E.g.
sometimes you should treat via eight
extras, rather than six divisions.

Comment [u16]: You must determine if

this is the correct approach to the
condition being treated. In some
instances, it is. I would suggest that in this
practice question it is not appropriate and
you would be marked down accordingly.

It appeared from some answers that students were attempting an energic approach to the problem.
That is, having identified a lung qi and spleen qi deficiency, they then set about selecting points that
tonify lung and spleen qi. This approach is legitimate, but the following needs to be taken into
consideration:

How many points are you going to use

How are you selecting the points think about why you would use lung 7 instead of Lung 9
or vis versa
What is the process of choosing the points
o Basing it on point function only
o What about meeting of channels
o Are you building of a single point to build up treatment or using a different or more
random approach

Comment [u17]: These points answer

the why question of the purple
highlights.

Here are the beginnings of what an answer might look like:

Objective: to treat Lung and Spleen qi deficiency
Two points will be used in this treatment Lung 9 and Spleen 4. These points have been chosen for a
number of reasons. The specific functions will be described below and the two points will have
synergistic effects that support each others functions to achieve the treatment principle of
tonification of lung and spleen. On a more general level however, the points have a six divisional
relationship as points on partnered channels of Tai Yin. As the predominance of symptoms relates
to the Tai Yin division, the relationship of qi and blood in this division can be strengthened by using
points that are only related to the lung and spleen. You can continue to expand on this point by
looking at things like:

Comment [u18]: I have chosen two

points. It could easily be three or four or
whatever number you feel is appropriate
as long as you justify your approach.

Comment [u19]: Here you

demonstrate your ability to think outside
of the box by noting other relationships
Comment [u20]: Here you would link
back to your original diagnosis and
treatment principle

What are the functional relationships of qi and blood in this division

How will supporting those functions help in achieving your desired treatment outcome

You might then go on to discuss the individual point functions:

Lung 9
Earth , Yuan , Shu point. Regulates and strengthens lung function. Removes phlegm, Clears wind
(receives transverse luo from LI6)
Stating these functions is not enough. It does not indicate that you understand what this means.
For example: as a Yuan point, lung 9 will bring yuan energy into the lungs via the divergent channel
pathway. The Yuan qi will be used as a catalyst to stimulate lung function. This is appropriate
because the deficiency in this case is mild. If there was a sever deficiency, there would be a risk of
the Yuan qi being consumed. In such a case an alternative of Lu 7 would be more appropriate as it
also stimulates lung function by drawing qi from the eight extras or large intestine channels instead
of consuming yuan qi.

Page 5 of 7

Comment [u21]: Keep this sort of

information in the back of your mind as
you might find it relevant to your case.
Could it for example help in the treatment
of the headache? In this case, you are not
needling LI6, but by potentially drawing qi
from the LI Luo mai which may be in
excess, you might relieve the headache
whilst bringing qi to the lung organ which
will assist in the lung deficiency. However
you have to decide is this a solid or
tenuous explanation. If it is too tenuous or
tangential, then it may not be worth
mentioning or if mentioned, should be
pointed out as tenuous.

You might speak about how lung 9 strengthens Tai Yin via the sheng cycle (Rogers and Rogers, 2012)
but unless you can explain how this happens and what this means in the context of your treatment
then all you have done is copy out an explanation or fact from a text book. This will not gain you
marks.
There are a number of relationships to liver function that could be made. The metal functions of the
lung element assist in the control of the liver blood and vessels. Within the five elements, there is
Ke cycle controlling relationship over the liver you can build in a number of secondary relationships
to the blood deficient symptoms
If you are discussing the point functions you need to :

Determine which ones are important and relevant to your treatment principle
Differentiate the primary functions from the secondary functions
Be able to explain how those functions affect the pathology and consequently support the
treatment outcome. Explain the primary functions first, and then how the secondary
functions may support the primary functions in the context of your treatment goal.

Comment [u22]: Remember its an

open book exam. I am testing your ability
to bring facts together in a meaningful way
and show that you understand how to
manipulate the application of those facts
to your purpose.
Comment [u23]: It is important that
you identify the primary aspects of the
point function from the secondary aspects.
What determines primary from secondary
depends solely on your emphasis and
things like point combinations.

Synergystic effects
Assuming you have outlined and explained the point functions in the context of the pathology of the
case in a way similar to the notes above, you must now look at the synergistic effects.
Lung 9: Earth , Yuan , Shu point. Regulates and strengthens lung function. Removes phlegm, Clears
wind
Spleen 4: Luo point, Master point of Chong Mai, couple of Yin Wei mai, harmosnizes stomach and
spleen.
You need to look for common functions that support each other and relate to the symptoms being
treated. You might go back to the explanation of lung9 and use this as your base point.
The primary purpose of using Lung 9 is to strengthen the Yuan qi of the lungs in the division of Tai
Yin. SP 4 supports this on a number of levels. As a point on the Tai Yin partner channel of the lung,
the combination of these points will strengthen the overall levels of qi in the division. As lung 9 is
also an earth point, it will bring this type of neutral energy into the division which will interact with
the yuan qi to support overall level of qi and qi production. SP 4 as the Master point of Chong Mai
will reinforce the effects of the Yuan qi as Chong mai will promote the circulation of Yuan qi. Chong
mai will also support the spleen in blood production and regulation. The dray air, pale complexion
and low spirits in this case relate to a deficiency of qi with secondary deficiency in blood (relating to
spleen blood production).
You can also talk about how Sp 4 and Luo point disperses emotional stress and restores the
distribution of blood and qi. One of the primary functions of the Lung is to distribute qi (Masters of
Qi). Consequently the two point reinforce the distribution functions of the lung and spleen through
the division of Tai Yin.
By following this process and looking at the links between functional activities you should be able to
build a case for synergistic effects.
Page 6 of 7

Comment [u24]: You can build in the

emotional symptoms of the case, worry,
melancholy etc

Relevant Needle Techniques why/how treatment outcomes are changed

The purpose here is to define and describe the correct technique that will support your treatment
principle and apply it judiciously to the correct point.
For example: A perpendicular insertion will be used. A simple tonification technique of rotation will
be used. The method employed will be Cuo rotation of the needle through a strong rotation of
greater than 180 degrees rotation. A clockwise direction will be used to tonify (reference). The
needle will be stimulated for 30 rotations every 5 minutes or until the patient identifies a de qi
sensation. This technique is the most appropriate for this condition because the underlying
deficiency is substantial as evidenced by the predominance of deficiency symptoms and
consequently a stronger technique is required. As the patient is young, she should be able to cope
with stronger forms of stimulation.

Comment [PM25]: If you are using an

oblique insertion you would explain, why,
the direction etc.
Comment [PM26]: You could easily use
a nian gentle rotation less than 45
degrees but you should explain why.
Comment [PM27]: As there is
substantial controversy over direction of
rotation and its link to tonificiation or
sedation, and as this is an open book exam,
if you are making a claim like this, you
should reference it.

You need to consider and explain:

Why is a de qi senation relevant to your treatment. Some treatments only require a neutral
technique (no de qi sensation). In other instances you might seek de qi stimulation only at
the beginning of the treatment rather than all the way throughout.
You need to consider the anatomy at the point and explain differences in depth that you
would use and how this affects the type of needle technique.
You need to take all other factors into account in choosing the technique such as age,
constitution, underlying pathology, presence of damp or other factors that slow qi reactions
etc

Comment [PM28]: Is the above

technique suitable to Lu 9? If not, what is
an alternative?

Additional modalities why/how they change the outcome

The same principles outlines above apply to the use of additional modalities such as moxa or
cupping or gua sha etc.
For example: on SP4 a sparrow pecking technique will be used. This involves using a stick of moxa
and moving it above the point in a pecking like fashion through a distance of approximately 2 cun.
This will be done until the patient feels a needle like sensation and will be carried out for no more
than 5 minutes. The primary purpose of this technique is to send penetrating yang energy deep into
the point. This will have the effect of

Comment [PM29]: I have given a

simple example. You need to determine if
this is the correct technique for the
treatment at hand and if sparrow pecking
is even suitable for SP4. If sparrow pecking
is not used for this case, then what is the
appropriate method..

When explaining the use of moxa techniques you need to:

Consider the appropriateness of the technique to the treatment outcome and patient
Are you using moxa to cool or heat, tonify or sedate
Point selection is crucial so you should explain why you are using moxa on a particular point
and not on others and this needs to be related back to the point function and the patient.

You should also consider any other modalities that are relevant to the case. In this question, cupping
would not be appropriate. If however there was a case history in the exam where cupping should be
used as an adjunct modality and you did not identify this, then you may not gain full marks.

Page 7 of 7

Comment [PM30]: It might be

appropriate to use moxa on a particular
point, but it might not be suitable for a
particular patient. This requires a
judgement call or a change of moxa
technique