Shoulder pain for several years

Date of first visit: Mar 16, 2009

Name: Mrs Age: 67yrs Gender:Female

Address & Contact No. :

Chief complaints

Shoulder pain for several years

Descriptions (4 diagnostic methods)

A: Asking

Current condition	There was no injury happened. She doesn’t remember when the pain started. The pain is always there. Massaging the area with hot water makes her feel better. Her appetite is not bad and eats quite a lot. She likes spicy food and doesn’t drink water too much. She has no problem with urination because she had an operation for frequent urination 10 years ago. She has a normal defecation. Normally she goes to bed at 12 and wakes up at 5 but she is difficult to go to sleep and easy to wake up. She wakes up often during the night and has a lot of dreams. She has no sweating, aversion to cold and cold in 4 limbs. Low back pain
Past history	She has an inflammation in ST and took a medicine 2 years ago.
Life style	Pensiveness, worry, angry. Her husband is sick and lives in a rest house. Her family is in Korea and lives alone now Playing golf regularly
Family history	Mum and granddad with hypertension
Menstruation	NAD

B: Inspection

General	Short and thin, vitality 6/10
Others	NAD
Tongue	Teeth marks, thin white coating

C: Auscultation/ Olfaction

Sound	Tinnitus on the right ear for 4~5years
Odour	NAD

D: Palpation

Body area	NAD
Pulse	Slippery

Case Summary

Definition: Pain in the shoulder which may be aching, dull, or stabbing in character. In the case of a sudden occurrence, the pain may be severe with the upper arm and the elbow involved.

There is atrophy of the muscles in the shoulder with more than two sensitive tender points. For instance, under the acromian or in the anterior part of the shoulder.

Both active and passive movements of the shoulder joint are limited, especially abduction, external rotation and elevation.

WMS

Description: What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion to the arm, from scratching your back to throwing the perfect pitch. Mobility has its price, however. It may lead to increasing problems with instability or impingement of soft tissue resulting in pain. You may feel pain only when the shoulder is moved, or all of the time. The pain may be temporary and disappear in a short time, or it may continue and require medical diagnosis and treatment.

Causes: A common cause of shoulder pain is soreness of the tendon (a cord that attaches a muscle to a bone) of the rotator cuff (the part of the shoulder that helps circular motion). Another common cause is soreness of the subacromial bursa (a sac of fluid under the highest part of the shoulder). You might experience soreness after activities such as painting, lifting or playing a sport, which require you to lift

your arms. Or you may not remember any specific injury.

The main joint in the shoulder is formed by the arm bone and the shoulder blade. The joint socket is shallow, allowing a wide range of motion in the arm. The rotator cuff is made up of 4 muscles that surround the arm bone. This cuff keeps the shoulder steady as the arm moves.

Teatment: Treatment generally involves altering activities, rest and physical therapy to help you improve shoulder strength and flexibility. Medication may be prescribed to reduce inflammation and reduce pain. If medication is prescribed to relieve pain, it should be taken only as directed. Injections of drugs may also be used to treat pain. Surgery may be required to resolve shoulder problems; however, 90 percent of patients with shoulder pain will respond to simple treatment methods such as altering activities, rest, exercise and medication. Certain types of shoulder problems, such as recurring dislocation and some rotator cuff tears may require surgery. Common sense solutions such as avoiding overexertion or overdoing activities in which you normally don't participate can help to prevent shoulder pain.

TCM

Etology & Pathology

1.Wind-cold : Acute pain in the shoulder joint that is aggravated by exposure to cold and application of het, a feeling of cold

2.Damp-cold : Ache in the shoulder region that may extend to the scapula region, a feeling of heaviness, numbness, coldness on palpation.

3.Stagnation of Qi and stasis of Blood : Pain in the shoulder joint, rigidity of the shoulder, a feeling of distention

TCM diagnosis : Shoulder pain

Syndrome differentiation : Qi and Blood stasis underlying SP and KD Yang deficiency.

Explanation:

She has the symptoms of KD yang deficiency, marked by low back pain, tinnitus and cold in 4 limbs.

KD yang is primary yang so it could affect SP yang deficiency and she has the symptoms of SP yang qi deficiency, marked by teeth marks ,being tired all the time and aversion to cold.

SP deficiency causes the poor function of transformation and transportation and the reason of the pain in the shoulder area is the SP deficiency.

Treatment principle:

1. Circulate the Qi and Blood on the local area

2. Tonify SP and KD yang

Treatment Points and their roles:

1. Bingfeng, Naoshe, Tianshong : as local points

2. Houxi : as a distal point

3. Mingmen : Supports the LR, tonifies blood and KD and expels wind

4. Shenshu : tonifies and harmonises the KDs and strengthen the loins and benefits the ears and eyes.

5. Pishu : tonifies and harmonises the SP

Life style advice

1. Keep doing exercise, but walking instead of golf.

2. Massage the area gently for the good circulation of Qi and Blood.

3. Try to free from stress and worry by making friendship.

4. Treat Insomnia. (advised her to have an acupuncture treatment for that)

Follow up

1. First follow up at Mar 19, 2009

Not much changed. Taking the points as same as before

2. Second follow up at Mar 23, 2009

The shoulder pain has much improved, but Tinnitus is getting worse on the right.

Points : + Tinghui and Taixi.

Chronic cough for 3 years

Date of first visit: 05/3/2009

Name: Mr Mike Lee Gender: male Date of birth: 1/2/1959

Chief complaints: Chronic cough for 3 years

Description (4 diagnostic methods)

A. Asking

Present illness complaints: Mr Lee is 50 years of old. He has suffered from the chronic cough for 3 years. He was infected with a chronic cough from a person who had a cold. He has a cough on and off. He expectorates scanty and sticky phlegm occasionally. He has a tidal fever in the afternoon, itching throat but no sweating. He sleeps less time than average people’s but falls asleep immediately. He doesn’t separate cold or warm drinks. He has good appetite, normal defecation and yellowish urination. He took herb medicine for about forty days at the first time of the cough without western medication.

Past history: TB in the lung about 20 years ago and cured completely.

Lifestyle: Staying awake, alert status, pleasant, appreciates ecstatic beauty of nature, and busy

Family history: His father died of colonoma.

Marital history: Married with 2 children

B. Inspection

General: Vitality 9/10

Others: NAD

Tongue: Slightly red color with swollen, thin white coating

C. Auscultation/Olfaction

Sound: NAD

Odours: NAD

D. Palpation

Body areas: NAD

Pulse: thin and weak

CASE SUMMARY

Definition:

Chronic cough is usually defined as a cough lasting more than three weeks. Chronic cough is not a disease in itself; rather it is a symptom of other disorders.

WMS

Description:

Cough is a common presenting complaint in the frontline physician’s office, but in most patients the symptom is self limiting. In others, symptoms may persist from weeks to years and are associated with significant morbidity. Successful treatment depends on finding the cause and initiating specific therapy. The most common causes are cigarette smoking, asthma, post-nasal drip, GERD or post-viral respiratory tract infection. Multiple causes in the same patient are common. When the cough persists in spite of specific or empiric therapy and either the physician or the patient is dissatisfied with the diagnosis or treatment, referral to a specialist should be considered.

Causes:

(1) Cigarette smoking is the most common cause of chronic cough.

(2) Asthma; which is a disease of airways, resulting in difficulty breathing or wheezing.

(3) Postnasal drip and sinus problems; This condition can be difficult to detect. Sometimes CT scan of the sinuses is necessary for diagnosis.

(4) Gastroesophageal reflux disease (GERD); Some foods may increase reflux.

(5) Infections such as bronchitis or pneumonia; These infections can be caused by virus, bacteria or fungus.

Treatment

The treatment of cough is determined by the causes; Asthma – steroids and bronchodilators, GERD - selecting foods to take, Nasal or sinus problems – decongestants or antihistamines, Infections- antibiotics. However, patients may get symptomatic relief from over-the-counter cough medicines containing guaifenesin and/or dextromethorphan, drinking lots of water, inhaling steam, and using cough lozenges. In severe cases a doctor may prescribe codeine, which is an effective cough suppressant. It is very important to obtain a chest x-ray if a chronic cough is prolonged. For the minority of patients in whom this diagnostic approach is unsuccessful, consultation with a pulmonary specialist is appropriate.

TCM

(1) Invasion by the exogenous pathogenic factors

The lung dominates Qi and is regarded as an umbrella protecting the five Zang-organs. It governs respiration and associates with the skin and hair externally. Once the lung is attacked by the exogenous pathogenic factors the lung Qi is blocked and fails to descend, thus resulting in cough. The exogenous pathogenic factors attacking the lung is divided into two types: wind-cold and wind-heat.

(2) Internal injury

Cough resulted from functional impairment in the Zang-Fu organs, falls into the category of cough due to internal injury caused by deficiency of yin with dryness of the lung leading to failure of Qi of the lung to descend; and caused by the deficiency of the spleen which gives rise to internal dampness whose excessive accumulation produces phlegm.

SYNDROME DIFFERENTIATION: Internal injury

(1) Blockage of the lung by phlegm

Main manifestation: Cough with profuse, white and sticky sputum, stuffiness and chest congestion, loss of appetite, white, sticky tongue coating and rolling pulse.

(2) Deficiency of yin with dryness of the lung

Main manifestation: Dry cough without sputum or with scanty sputum, dryness of the nose and throat, sore throat, spotting blood or even coughing blood, afternoon fever, hot flush, red tongue, thin coating, rapid, and thready pulse.

TCM Diagnosis: Cough

Syndrome Differentiation: Lung yin deficiency (with dryness)

Explanation:

There are several manifestations of Lung yin deficiency (with dryness) such as scanty and sticky phlegm, a tidal fever in the afternoon, itching throat, red color tongue with swollen, thin white coating and thin and weak pulse. Some manifestations like cough, itching throat and thin white coating are relevant to wind-cold syndrome.

Treatment Principles:

Nourish yin. Eliminate dryness and descend lung qi.

Points, Therapies and Explanations:

Feishu BL13 & Zhonhfu LU1; To nourish lung yin and regulate lung qi

Lieque LU7; To be connect with conception vessel to descend lung qi and

relieve cough

Zhaohai KID6; Combining with Lieque to nourish yin and clear the throat.

Pishu BL20; To regulate the qi of middle jiao.

Dingchuan EX-BW1; To stop a cough

Life Style Advice

Do regular exercises to strengthen body

Take appropriate sleep and rest

Drink more water

Keep fresh and clean air environment

CASE CONCLUSION

The patient’s chief complaint is to have a chronic cough for three years. The diagnosis is Cough and the syndrome differentiation is Lung yin deficiency (with dryness). It results interior functional impairment in the lung leading to failure of Qi of the lung to descend which causes cough. The treatment principle is to nourish yin and to descend qi. The chosen points are Feishu BL13 , Zhonhfu LU1, Lieque LU7, Zhaohai KID6, Pishu BL20, and Dingchuan EX-BW1.