Record of first visit
Date of visit
Gender M
Age 30
____________________________________________________________________________________
Chief complaint :Sinus obstruction with headache for 6-8 months
DESCRIPTIONS
ASKING Numb face and headaches for 6-8 months, the headaches are behind the eyes and in the temple region generally the right side, pain can be quite sharp and strong. He first notice his face going numb when having cold a beer on an empty stomach, the face goes numb mainly in the area of both cheeks and brow, the feeling is heavy and dull ache with reduced feeling to touch, No type of weather seems to affect it he has noticed it gets much worse while driving and only recently it has started to occur after eating sweet food this also produces phlegm in his sinus (nose becomes blocked and heavy) In the morning he can get phlegm out of his sinus but very small amount and white colour. He also often gets dizzy and has permanent floaters in his vision. No chill or fever
His right ear feels like he has fluid in his ear drum, has ok appetite, often feels low energy and wakes up tired and a heavy feeling in his limbs particularly the legs. Once he has done some exercise he is ok. He often gets cold feet with a general adversion to cold, he often has an achey lumbar with no record of injury, no tinnitus, also has a pimple like skin rash around the mid of his back area, he said it comes and goes with no regular pattern. His sleep is okay but very dreamy and often has night sweats (very Bad in summer). Slight palpitations thirsty and prefers cold water. His defication is irregular and loose not much smell, urination 7+ per day but not at night.
His doctor has recently prescribed antibiotics which he is now taking
Present illness Na
Previous history High colesterol
Maritial Lives with partner un married
Family history Mother passed away from melanoma (4 years ago- grief), father high colesterol
Lifestyle Non smoker drinks 15 beers per wk reg exercise
INSPECTION
General body Vitality looks slightly pale 7/10
Tongue Pale corpulent not much coating on the middle and slight yellow greasy coating only on the rear
Pulse Right slippery moderate, weak chi deep
Left slippery moderate, weak chi deep
AUSCULTATION
Sound/Odours
PALPATION
Abdomen Palpation numb feeling around brow and nose and beneath eyes.
| · TCM Disease: | Sinusitus |
| · TCM type/pattern: | Phlegm retention in local area Sp and lu qi def, underlying kd yang def |
| · C) Explanation: | The phlegm retention In the local area has been caused by the weak lung qi which may have been caused by (grief) and also through the mother child relationship, the lungs mother is the sp. So if the mother is sick eventually so will the child, The spleen being impaired through over thinking and lifestyle and diet. Also he has some kd yang def signs if the kd yang warming and steaming function is weak then his symptoms can result in cold limbs and slightly frequent urination and achey lumbar also night sweating. |
| TREATMENT: | |
| A) Treatment Principle | Eliminate local phlegm stagnation and tonify sp and kd, |
| B) Treatment Method | |
| 1. Needling | |
| Select techniques: | Filiform ( * ) three edged needle ( ) plum blossom ( ) intradermal ( ) |
| Select Acu-points and Manipulation: | Xing xiang, yin tang, tai yang, hegu, zhong wan, qi hai, fenglong |
Resons for
point selection To use local points as he doesn’t have any other major lung qi signs so treat the local area and strenthern the mother to treat the child.
This was his first time using acupuncture unfortunately for him and me the recommended points were
ying xiang, yin tang for local area qi stimulation and phlegm reduction, tai yang and hegu for his headaches, zusanli for his sp qi, qi hai for his kd and fenglong to eliminate phlegm.
Lifestyle advice Avoid damp foods like dairy and wheat, also avoid cold drinks try some light exercise like walking. Ginger tea in the morning and warm meat like lamb would be good. Also deep breathing over a bowl of steaming water with eucaliptis oil in it can relieve the symptoms.
Follow up treatments treatment 2-4
He hurt his back snowboarding and had pain in the hypochondriac region and lumbar but could not locate any specific ashi points, Also is still has headaches and same nunb pressure on forehead and temporal region, Antibiotics has no effect yet.
Ming men, Shen Shu, Pi Shu, Fei Shu, Dachang shu, Yao tong dian(moving lumbar for 10 min) fenglong.
Third and fourth treatment no
Treatment 5 Still has some frontal and lateral headaches and feels dizzy walking, still eye floaters, red eyes and hypochondriac pain, also complained of tight feeling in legs and still nasal congestion.
Yin tang, ying xiang, shangxing, hegu, yangling quan, tai chong, fenglong
I chose shang xing for his headache, tai chong for his red eyes and stimulating the GB and LR, Yang ling quan for his tendons.
This treatment he found a very strong feeling on his forehead and relief from pressure In his sinus.
The following treatments I included zulingqi (draw GB heat down) and zang men as his pain in the hypochondric region has become more constant, also as he has high cholesterol,
I palpated his GB channel and there was great tenderness all along the channel.
With having little improvement previous I have decided to use more gallbladder points, by the 7th treatment his sinus has improved greatly and he has hardly any numb feeling and his smell has improved, his energy has increased and eyes not as many black spots or as red.
Case Conclusion: This patients results were a little slow in coming as he hurt is back and this changed the treatment focus from the original complaint. I also discovered that if I manipulate (ying xiang and yin tang) the needles with quite strong manipulations while asking him to breathe deeply it seems to have a good effect combining this with shangxing he had a great relief of pressure so will try this combination in the future. I have found it very interesting that once we started to use the gallbladder points that he had a quick response to an improvement in his sinus and headaches, I have found that palpating along the meridian useful and will use this again to aid me in my diagnosis. Also I found using
Western medicine
Definition Sinusitis is an infection or inflammation of the lining of the air filled cavities in the skull, these cavities are located above the eyebrows in the forehead behind the nose and just below the eyes. The most common cause or this condition is thought to be a viral, fungal, bacterial infection of the respiratory tract leading to obstruction. There are four types of sinusitis depending on its location, maxillary (cheeks area) frontal (behind and above eyes) ethmoid (between the eyes) sphenoid (eyes and vertex).
The standard treatment is to usually prescribe antibiotics in the acute (4-12 weeks) The first 7 days it is thought to be viral infection and is often confused with the common cold, then after 7 days, 30 to 50% of the cases seem to be in a bacterial stage (antibiotics have effect) and then later on if this has no success then anti-inflamatorys and corticosteroid nasal sprays are prescribed. A recent study in britian has found that nasal corticosteroids work no better than a placebo {1}
Cronic (12 wks) or more sinusitis is more difficult to treat and saline nasal sprays and nasal irrigation using a “neti pot” are often far more effective than weeks of antibiotics. The other option is surgery to remedy the problem.
Here is some instruction on how do the nasal irrigation.
http://www.brown.edu/Student_Services/Health_Services/Health_Education/general_health/sinusitis.htm
One or 2 minutes a day spent performing nasal irrigation is often more effective than weeks and weeks of antibiotics, decongestants, and cortisone nasal sprays, and has none of the side effects of these medications. Even if you do require medications or surgery, the improved cleanliness of the sinuses makes it more likely that these treatments will be effective.
How do I irrigate? First, it is important not to use common table salt to irrigate the nose on a regular basis, because it contains certain chemicals such as iodine and "anti-clumping" additives that can be harmful if used frequently. You can use Kosher salt (found in most groceries right along with the table salt) or sea salt found in health food stores.
With a measuring spoon, add 1 teaspoon of salt to the Neti Pot and fill it with warm tap water. Stir very thoroughly. The salt water usually doesn't sting but the salt particles will if they are not dissolved well. You can use a little less than a teaspoon at first if it feels more comfortable, but after a few days there should be no discomfort at all and you can mix it a little stronger.Lean over the sink, tilt your head to one side (it should be almost flat-one ear up and one ear down), and put the spout of the Neti Pot into the upper nostril. Pour the salt water slowly into your nose while you continue breathing through your mouth. The water will flow into the upper nostril, turn the corner at the back of the nose, and trickle back out the lower nostril. When the pot is about half empty, stop, turn your head the other way and repeat the process.Let the water drip out, then gently blow your nose. You will probably need to blow it several times in the next few minutes as your sinuses drain.
How often should I irrigate? After you do this a while, you'll find what works best for you (and it does vary from one person to the next). Start off irrigating once in the morning and once in the evening. There is no harm in doing it 3 to 4 times a day and it may be useful to do so if you have a lot of drainage. If after a week or so your nose seems much clearer and you are not having much drainage during the day, reduce it to just one irrigation in the morning. You may continue this indefinitely, or you may only irrigate when you feel the congestion or postnasal drip is recurring.
Hot Compresses Hot compresses to the sinuses also help as they promote movement of the tiny hairs that line the nasal cavity, cleaning mucus and pus. Simply moisten a facecloth with warm water and lay across forehead (above the eyes) and/or cheekbones for 5 minutes three times a day. Placing a dry facecloth over the heated wet one will help retain heat for the full 5 minutes.
- {1} ^ Ian G. Williamson et al. (2007). "Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis". JAMA 298: 2487–2496. doi:10.1001/jama.298.21.2487. PMID 18056902.
Syndromes causing sinusitis
Wind heat of lung mainly caused by weather changes
Deficiency of spleen/stomach
Mainly caused by greasy and spicy foods and over thinking.
Deficiency of cold lung qi
Mainly caused by chronic illness
Stagnated heat of the gallbladder
Mainly caused by emotions
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