Feeling lump in throat for 10 years

Date of First Visit : 25 aug 2008 Name : Mr park

Date of Birth : 58yrs Gender : Male

CHIEF COMPLAINTS : Feeling lump in throat for 10 years

DESCRIPTION

A) Asking

Present illness history : He is a 58 years old man who had been suffering from uncomfortable throat for 10 years. He had been feel some lump in throat. He has been difficulty expectoration or swallow it. He has been to try on cough for spit it out. But he can not success. Some times he has been feeling heaviness on temple area on head. It has been on off. He has been blurred vision, dry mouth and tongue. He get up early in the morning, he has slight numbness of hand, joint and knee. He has good appetite and easy hungry. Urination is small and frequent 2-3 times at night, sleeping is normal, no insomnia, normal dream, defection is loose twice per day. No sweating, no chill and fever.

Past illness history : He has been treatment for strain liver 15 years ago

Life style : Hard working. No smoking and no alcohol

Family history :

Menstruation , marital and obstetrical history :

B) Inspection

General : Vitality 7/10, Strong body, looks high energy.

Tongue : Purple tongue, slightly yellow coating. Crack of middle area

C) Auscultation / Olfaction

Sound : Loud and strong

Odour : Nothing Abnormal Detected

D) Palpation

Pulse : Wiry and deep weak

Body area : NA

E) Physical Examination :

CASE SUMMARY

DIAGNOSIS

A) Diagnosis : Plum-pit qi (Mei He Qi)

B) Syndrome Differentiation : Stagnation phlegm and qi of the Lung & stomach

C) Explanation

Stagnation of phlegm and qi in the throat and disorder of dispersing and decending function of the Lung & stomach

TREATMENT

A) Treatment principles

Sooth the flow of qi and resolve the phlegm

B) Treatment Methods

1. needling

Prescription

- Tian tu(REN-22, Neiguan(P-6), Fenglong(ST-40), Taichong(LR-3), Taixi(KD-3)

- Explanation

Tian tu(REN-22) : resolve the phlegm and decending the Lung qi

Neiguan(P-6) : move the Liver qi

Fenglong(ST-40) : resolve the phlegm

Taichong(LR-3) : sooth the qi, resolve the dampness

Taixi(KD-3) : strengthens the Kidney’s receiving of qi

2. Moxibustion

Prescription :

Explanation

3. Cupping

Prescription :

Explanation

-

4. Electro Acupuncture

Prescription

Explanation

5.Microsystems

Select Microsystems : Ear( ), Hand ( ), Foot ( ), Nose ( ). Other ( )

Prescription :

Explanation :

6. Life style Advice

· Yoga or meditation to relieve stress and gain more qi

· Taking A B complex vitamin can also help alleviate stress.

· Do regular exercise to strengthen body

· Have a fresh air environment

Follow up consultation

Patient name : Mr park Treatment Number : 2

TCM disease : Plum-pit qi (Mei He Qi)

TCM type/pattern : Stagnation phlegm and qi of the Lung & stomach

Date : 01/09/2008

Current conditions/change :

He get better after treatment. But he has little feeling in throat. He has been feeling normal.

Treatment Principle :

Sooth the flow of qi and resolve the phlegm

Regulate the Lung & Stomach

Explanation :

Tian tu(REN-22) : resolve the phlegm and decending the Lung qi

Neiting(ST-44) : open the chest and remove qi and blood

Tanzhong(REN-17) : open the chest, regulates qi and promote the decending qi

Hegu(LI-4) : harmonizes the ascending and decending of qi

Taixi(KD-3):strengthens the Kidney’s receiving of qi

Lifestyle Advice :

· Yoga or meditation to relieve stress and gain more qi

· Taking A B complex vitamin can also help alleviate stress.

· Do regular exercise to strengthen body

· Have a fresh air environment

Case conclusion

I finished this case with 2 treatment. The patient said my throat is more comfortable after treatment. I think the treatment was effective. I will try those points again next time. Also, I recommend to do Yoga, and do light exercise such as taking a walk in the fresh air.