Facial wrinkles for 3 years

CHIEF COMPLAINT:	Facial wrinkles for 3 years
DESCRIPTION: (4 diagnostic methods)
A) Asking
Present illness complaints:	She indicated facial wrinkles getting more around the mouth , intakes vitamin C and E oral supplement everyday , she felt very stressful for her lifestyle, likes to take sunshine bath around one hour per day if good weather , nasal congestion a long time , difficult to fall asleep if wake up in midnight , numbness and dull pain at finger and shoulder (both side) normal appetite ,sleep, urination , defecation(a little bit hard stool discharge not very smooth) ,sweating when do heavy job at day time , prefer sweet , spicy foods.
Past history including past health conditions and other previous illness:	NAD
Life Style:	part time job for 5 working days
Family history:	Father : high cholesterol , mother : cancer died
Menstruation, marital & obstetrical history / Men’s sexual health	single ,never married
B) Inspection
General:	Vitality :6/10
Others:
Tongue:	Purple dim color , no coating
C) Ausculation / Olfaction
Sound:	lower voice
Odours:	NAD
D) Palpation
Body Areas:	NAD
Pulse:	R - Rapid , hesitate      L : rapid ,week at chi
DIAGNOSIS:
A) Patients condition is classified	Aetiology (  v   )                                Fundamental Substances (  v   ) Zangfu (   v  )                                Jingluo (    v   )
B) Diagnostic Conclusion
TCM Disease:	Facial wrinkles
TCM type/pattern:	qi and blood def. due to lung & spleen disharmony ,
C) Explanation:
TREATMENT:
A) Treatment Principle	Strengthen spleen ,regulate qi and blood , smooth liver qi
B) Treatment Method
1. Needling
Select techniques:	Filiform ( v    )                 three edged needle (    )                      plum blossom (    )                      intradermal (    )
Select Acu-points and Manipulation:	dingchuan ,chengjiang ,jiachenjiang ,taichong ,hegu xuehai,zusanli,  sanyinjiao , yinhsiang even method
Explain the reasons for your selection:	chengjiang : local point to strengthen qi and blood circulation ,jiachenjiang : local point to strengthen qi and blood circulation Dingchuan EX-BW1; local point to strengthen qi and blood circulation Yinhsiang : open channel to treat nasal obstruction taichong : smooth LV –qi circulation xuehai : tonify blood circulation zusanli : strengthen qi&blood sanyinjiao : nourish 3 yin meridians of LV/SP/KI hegu: for dispelling cold  symptom-complex
2. Moxibustion
Select techniques:	moxa cone (  )             moxa roll (  )                indirect moxa (  )
Select Acu-points:
Explain the reasons for your selection:
3. Cupping	N/A
Select techniques:	Stationary (   )            mobile (  )
Select Acu-points retention time:
Explain the reasons for your selection:
4. Microsystem
Select Microsystems:	Ear (     )               hand (    )       foot  (    )          scalp (    )          nose (    )    brow (    )             dentition (    )
Points	.
Diagnosis is confirmed by across checking with at least one other Microsystems system:
Explanation the reasons of your selecting:
5. Lifestyle Advice:
	Take appropriate sleep and rest, Drink more water  Keep fresh and clean air environment Prevent injury from UV by SPF 30 + cream

 

  

 

 

Case Conclusion

  She indicated that facial wrinkles getting more around the mouth , to intake vitamin C and E in order to promote metabolism of the body everyday , she felt very stressful for her lifestyle,It will disturb qi flow of liver due to emotion change and impare the function of middle jiao ,she likes to do sunshine bath around one hour per day if good weather , that UV light can damage skin layer made more wrinkles occurrences , nasal congestion for a long time , difficult to fall asleep if wake up in midnight , numbness and dull pain at finger and shoulder (both side), normal appetite ,sleep, urination , defecation(a little bit hard stool discharge not very smooth) ,sweating when do heavy job at day time , prefer sweet , spicy foods.

The diagnosis is facial wrinkles , syndrome differentiation is qi and blood deficiency due to lung & spleen disharmony , my treatment principles aids to strengthen spleen ,promote circulation of qi and blood , smooth liver qi , all apply needles to take even method manipulation and retaining needles for 30 minutes ,

This is my first time to time take dingchuan ,chengjiang ,jiachenjiang points by 0.5 cun needles for facial , she got very nervous .The patient no any further treatment due to our school will have study break for two weeks .