Pain in epigastria for 10 days

Date of First Visit: 23. June. 09	Name: xxxx
Age : 53	Gender: Female
CHIEF COMPLAINTS : Pain in epigastria for 10 days
DESCRIPTIONS (4 diagnostic methods)
A) Asking
The patient suffers from discomfort in epigastria for 10 days. There was some problem came up two weeks ago and the patient was worried and stressed about it. Then one day, it suddenly appeared after she had a dinner with severe cramping pain in the stomach. She had nausea and few times of vomiting. After the cramping pain has been relieved, she started having poor digestion and bloated sensation after eating. No aggravating factors for epigastric pain. Frequent belching and acid regurgitation present. No chill. No fever. Dry mouth and throat. Hard to fall asleep (sleeping well otherwise). Poor appetite. Normal urination. Fatigue. Constipated for 3 days. (Stool is usually loose.) Depressed.
Past illness history: NAD
Life style: Busy, stressed, likes coffee
Family history: NAD
Menstruation, marital & obstetrical history: Married with 2 children. 15yrs, 3/28-30, 23 Jun 09 (early menstruation). Dark colour menses, no PMS
B) Inspection
General : Vitality 7/10. Dim complexion. Slim body. Normal body movement Other : NAD Tongue : Pink dim tongue with white coating
C) Auscultation / Olfaction
Sound : Normal voice, Normal breathing Odours : NAD
D) Palpation
Pulse : Taut, weak in general Body areas : NAD

CASE SUMMARY

DIAGNOSIS

A) Diagnosis Epigastric pain

B) Syndrome Differentiation Liver qi stagnation attacking stomach

C) Explanation

Anxiety, anger and mental stress damage the liver, causing failure of the liver in dominating free flow of qi, adversely attacking the stomach, impeding its activity and hindering its qi descending, then pain appears. Without any unusual food intake, the epigastric could possibly be caused by emotional stress that she has been suffering so far. For the last few weeks, the patient has gone through emotionally hard situation and I personally think that this problem has been developed due to her mental stress and anxiety. Once stagnant liver qi attacked the stomach, she started getting frequent belching, acid regurgitation, and poor appetite, bloated sensation after eating and poor digestion. Also due to anxiety and stress, she has difficulty in falling asleep too. Pink dim tongue body with white coating and taut weak pulse also indicate weak middle jiao qi and interior syndrome due to emotional factor.

TREATMENTS

A) Treatment Principles - Relax the mind and spirit, soothe the liver qi and strengthen the middle jiao

B) Treatment Methods

1. Needling

Prescription : - Zhongwan+ / Neiguan- / Zusanli+ / Tianshu+ / Taichong-

Explanations : - Zhongwan is the Luo point of the stomach and it can harmonise the middle jiao qi as well as strengthen it. Neiguan is to relax the mind. Taichong is used for soothing the liver qi in order to remove the stagnation in the liver. Zusanli produces qi and blood and promotes its circulation and also strengthens the spleen and stomach. Tianshu, the front-mu point of large intestine is used to promote the bowel movement.

2. Moxibustion

Prescription :

Explanations :

3. Cupping

Prescription :

Explanations :

4. Electro Acupuncture

Prescription :

Explanations :

5. Microsystems

Select microsystems : Ear ( ), Hand ( ), Foot ( ), Scalp ( ), Nose ( ), Other ( )

Prescription :

Explanations :

6. Life Style Advice

Eat light food frequently in small amount each time

FOLLOW UP CONSULTATIONS

Date: 30 June 09

Treatment Number: 2

TCM Disease	Epigastric pain
TCM type/pattern	Liver qi stagnation attacking the stomach
Current condition/changes	Epigastric pain is still present with bloated full sensation. No acid regurgitation but frequent belching. Dry mouth with thirst. She had defecation but still got a feeling of unfinished. T: Pink tongue with white coating P: Moderate taut
Treatment Principle	same
Prescription	Add Xiawan
Explanation (if any Adjustments)	Xiawan for belching by descending the stomach qi
Lifestyle Advice (if any Adjustments)

FOLLOW UP CONSULTATIONS

Date: 03 July 09

Treatment Number: 3

TCM Disease	Epigastric pain
TCM type/pattern	Liver qi stagnation attacking the stomach
Current condition/changes	No distenstion in epigastria, heavy sensation (dragging down) presents. Dry mouth. Dry stools. Normal urination. Good appetite. T: Dim tongue with white coating P: moderate
Treatment Principle	Same, “clear heat”
Prescription	Zhongwan, Xiawan, Neiting, Zusanli, Sanyinjiao
Explanation (if any Adjustments)	Zhongwan is the Luo point of the stomach and it can harmonise the middle jiao qi as well as strengthen it. Xiawan is for belching by descending the stomach qi Zusanli produces qi and blood and promotes its circulation and also strengthens the spleen and stomach. Neiting to clear heat and Sanyinjiao to nourish yin fluid and harmonise the middle jiao.
Lifestyle Advice (if any Adjustments)

EPIGASTRIC PAIN

TCM DEFINITION
Epigastric pain refers to a syndrome manifested by frequent pain over the epigastric region and close to the cardia, so in ancient times, it was also named “cardiac pain” or “cardioabdominal pain”. It is commonly seen in acute and chronic gastritis, stomach or duodenal ulcer, functional stomach pain in modern medicine.
TCM ETIOLOGY and PATHOGENESIS
(1) Irregular food intake, raw and cold food and hunger injure the spleen and stomach, causing failure of the spleen in transportation and transformation and failure of the stomach qi in descending, then pain appears. (2) Anxiety, anger and mental depression damage the liver, causing failure of the liver in dominating free flow of qi, adversely attacking the stomach, impeding its activity and hindering its qi descending, then pain appears. (3) Generally, lowered functioning of the spleen and stomach, due to invasion of pathogenic cold, which is stagnated in the stomach, causes failure of the stomach qi in descending, then pain occurs.
DIFFERENTIATION
1. Food retention
Clinical manifestation
Distending pain in the epigastria, aggravated on pressure, belching with fetid odour, anorexia, pain aggravated after meals, thick sticky tongue coating, deep forceful or rolling pulse.
2. Attack of the stomach by the liver qi
Clinical manifestation
Paroxysmal pain in the epigastria, radiating to the hypochondriac regions, frequent belching, nausea, acid regurgitation, abdominal distension, anorexia, thin white tongue coating, deep taut pulse.
3. Deficiency of the stomach with stagnation of cold
Clinical manifestation
Dull pain in the epigastria, which may be relieved by pressure and warmth, regurgitation of thin fluid, general lassitude, think white tongue coating, deep slow pulse
TREATMENT PRINCIPLE
Clear heat, harmonise middle jiao qi, remove stagnation, calm the mind, warm and tonify SP/ST, remove cold stagnation
ACUPUNCTURE TREATMENT
- Primary points: Zhongwan, Neiguan, Zusanli - Additional points: (1) Neiting, Tianshu (2) Qimen, Taichong (3) Qihai, Pishu, Gongsun

CASE CONCLUSION

The diagnosis of this case is epigastric pain and the syndrome differentiation is liver qi attacking stomach due to mental stress and anxiety.

I gave her three treatments and at the third visit, most of patient’s symptoms appeared to be improved (only heaviness sensation inside the stomach is remained, appetite has been improved). I have used Xiawan and Neiting with the basic prescription of Zhongwan, Neiguan, Zusanli, Tianshu, Taichong. However it was still difficult for me to resolve her dry mouth and throat by needling.