Date of first visit: 17.Mar.2009 Gender: F Age: 52
Chief complaint/s(chronic or acute): Fullness abdominal for 2 weeks
Description (4 diagnostic methods):
A) Asking:
She has suffered from.fullness abdominal for 3 months
All the time she felt distention of her abdominal.
When she desire defication but can not do completely. Feel still somting inside with uncomfortable..Also she feel hot sensation of her face.
Her sleep is turibid (wake up 2~3times during sleep)
Prefer to a lot of warm water.
The symptom is relieved by rest, drinking warm water and takes less food.
Present Symptoms:
: Good appetite, no chill & fever, no abnormal sweating, no thirsty (prefers warm water), stool (once per day, with form, hard push out), normal urination, easy to feel tired,
Past history:
12 years ago she got injury of her neck( c-5,6,7)
Life Style: No smoking, house wife
Family history: NAD
Menstruation, marital & obstetrical history / Men’s sexual health
Menopause( 4 years ago) married with 3 children
B) Inspection: General: Little bit fat body shape, normal face complexion, vitality:6~7/10
No limitation of movement.
Tongue: Tongue Body: pink(pale) Tongue coating: thin,white, slippery
C) Auscultation/Olfaction:
Sound: low voice
Odours: NAD
D) Palpation:
Body Areas: normal
Pulse: weak and deep
Case Summary
Definition:
Abdominal distention refers to distention and fullness which occur in both the upper and lower abdomen. The stomach and spleen are located in the upper abdomen, while the small and large intestines are in the lower. Dysfunctions of these four organs may lead to abdominal distention.
WMS:
Abdominal Distention is the actual “physical” finding that the abdominal area is larger than normal. It can be caused by three different things: air, fluid and tissue.
There are continuous and intermittent distentions.
Continuous distention is swelling of the abdomen for a considerable period of time, with no signs of relief. The cause can be one of four things.
· Enlargement of an organ within the abdomen
· A tumor in the abdomen
· An increase of fluid around the organs in the abdomen
· Obesity
Intermittent distention can come and go and is usually triggered by ailments which inhibit proper digestion, and cause an accumulation of fluid or gas within the digestive system.
Distention Causes
One common cause is irregular digestion. When the digestive system is working properly, food is digested by chemical reactions and broken down into components. From these components the body obtains nutrients and energy to use as fuel.
Food that is not broken down is considered waste and is eliminated from the body. Some of the waste comes in the form of odorless gases and are easily handled by the intestinal canal.
When the body is not digesting properly, sulfur-bearing gases are produced and accumulate in large pockets. These gases stretch the intestinal canal producing the painful effect of bloating.
TCM Aetiology and Pathology
According to TCM, there are three causes that lead to Fullness abdomonal
(1) Irregular or excessive food intake impairs the stomach and intestines, causing dysfunction of transportation and transformation, thus the retained food is stagnated and blocks the flow of Qi, causing abdominal distention.
(2) Because of the weakened function of the spleen and stomach or ageing, long illness, and general debility, the spleen and stomach fail in their transporting functions, so the circulation of Qi in the stomach and intestines is impaired, resulting in abdominal distention.
(3) Abdominal operations may disturb the circulation of Qi in stomach and intestines, leading to abdominal distention.
TCM Diagnosis:
Fullness Abdominal
Syndrome Differentiation:
Spleen and stomach qi deficiency.
Explanation:
Abdominal distention is common in clinic.Distention and fullness are likely to occur in both the upper and lower abdomen.The ST is located in the upper abdomen,while the small and large intestines are in ,they jointly complete the stroge, Qi Def. of the SP and ST results in dysfunction of transportation and transformation.In this patientc symptoms are when she desire defication but can not do completely. Feel still somting inside with uncomfortable. Its related transportation and transformation function disorder of the spleen and the stomach
Treatment Principles:
Tonyfy Sp/ST Qi to promote transportation and transformation functions
Points and Therapies:
Filiform needles for the following points:
Zusanli(+), zhongwan,(+) qihai,(+) tianshu(0)
Explanations:
Zhongwan(Front-MU)/ Zusanli(Lower HE) :this combination to regulate the function of the stomach and intestine in order to maintain normal flow of Qi add relive distention.
Qihai: tonify Qi.
Tianshu:restors and harmonizes the flow of Qi in large intestine and desolve stagnation
Life Style Advice
l Massage around low abdominal area make circle right to left.
l Take meal regulary
l Have regular exercises. Movement, especially in the morning before breakfast, encourages bowel activity
l Eat natural fresh foods. Packaged foods contain more preservatives and are harder to digest.
l Avoid foods that are too cold or too hot. They increase the air intake during a meal.
l Avoid caffeine. It acts as a stimulate and can overexcite the digestive system.
Case Conclusion
The patient was KIWI people. I am very worried with this patient with communication for diagnosis.
But it’s no problem because she know well Chinese medicines even acupuncture. She have experience with other student in our school..she know acupuncture is very effective for humen disease.
The points and manupulationmethods I used for this patient are proved to be helpful to the illness because the patient does not came for 2nd treatment. It’s means fully recoverd her symptoms. So I would apply them to other patients again.
