Blood in Stools for 3 days

Date of first visit:  19/09/2011                                               Name:  Mr. Bob

Date of birth:  21/09/78 (30 years old)                                  Gender:   Male

Chief complains:  Blood in Stools for 3 days

Descriptions (4 diagnostic methods)

A: Asking

Present illness complaints: Blood in stools from 11 am 3 days ago, No pain and he could see pink colour in water and on toilet paper. Dark colour stools with not much smell. Same day 2pm ate a chicken sandwich and a cold juice. Then darker stool much looser dark crimson colour "blood" with a much larger quantity not smelly thick creamy. Day 2 not as severe as first day but still stools with blood. Day 3 today same as day 2.

General :                           Defecation 6.30 am wake up have to go to toilet loose stools most days not much smell generally a darker colour often sticky  feeling afterwards and needs to go  again at 8.00 am. Twice in the morning and twice after lunch, urination 4 times per day not normally at night, usually clear colour.  He often coughs up large amounts of phlegm in the morning this has black spots in it. Not much thirst prefers cold drink 6 glasses per day. He has good sleep 10 pm to 6.30 am. Dreamy, easily sweats has night sweats lower part of the body legs and lower abdomen. No headache, No back pain easily short of breath with slight amount of exercise occasionally has heart burn quite bad 3-4 weeks ago. Heavy sensation of chest and body with general lassitude, low appetite doesn't eat breakfast, no chill or fever, salty flavor in mouth. Poor vision got glasses when was 12, is near sighted, no dizziness often sees floaters, Often has cold hands and gets pins and needles at night sometimes they are swollen.

Past history:                            Had Giardia 18 months ago with blood in stools and chronic diarrhea. Has had problems with his ears since a child and had his first operation when 7 years old. (To relieve pressure on his ear drum from excess wax) has had on going problems with his ears since and been on medication. Last time he had his ears syringed was 14 days ago usually every 3 months.

Lifestyle:                              Office worker drinks beer 15 bottles per wk., non smoker.

Family history:                     Mother nearly deaf from excess fluid in ear

B: Inspection

General:                              Complexion /  Pale complexion with slight puffy or mild edema on face and whole body.

Others:                                Tongue/ Reddish with dark bluish in middle Coating thick yellow coating, greasy       

C: Auscultation/Olfaction

Sound:         Nothing abnormal detected

Odours:       Nothing abnormal detected

D: Palpation

Body areas:   Nothing abnormal detected 

Pulse:             Right slippery KD deep weak  , Left slippery KD deep weak

Case Summary

WMS: Ulcerative colitis

Definition:

It is a long term chronic condition affecting the colon also known as the large intestine this condition causes the inflammation of the intestines. The condition causes the colon to be inflamed, and in severe cases ulcers form on the colon. These ulcers can bleed and produce mucus and pus. Symptoms of ulcerative colitis include bloody diarrhea occasionally abdominal pain and a frequent need to go to the toilet, the condition can vary from mild symptoms to severe, and this can cause weight loss in severe cases and can seriously impact on their quality of life.  Ulcerative colitis is an unpredictable condition; symptoms can flare up and then go into remission for months or even years. The causes for the condition are unknown but both environmental and genetic factors are involved. This condition normally appears in people between the ages of 15 and 30 and is more common in people of European descent. There is no current cure for ulcerative colitis but some successful treatments can relieve symptoms in up to 70% of all cases, in severe cases they remove the whole colon! In 20% of people who have ulcerative colitis has a relative with the same condition.  The environment can cause the condition such as through the diet, air pollution, hygiene however no factors have been positively identified, but the most common theory is that through a virus or bacteria an infection occurs (ulcer)(giardia the bacteria infection he had 18 months ago forms cysts on the intestinal wall which eventually can turn into ulcers) the body’s immune system responds to the infection causing a inflammation and for some reason in the case of ulcerative colitis the immune system doesn't seem to turn itself off once the infection has passed and it continues to cause inflammation.  The symptoms include abdominal pain, bloody diarrhea with mucus, general fatigue, and loss of appetite, fever dehydration, and tenesmus. Symptoms are often worse first things in the morning. These symptoms can go into remission for months or even years where they experience little or no symptoms however in all cases with no treatment the symptoms will return. There seems to be no specific triggers but stress is thought to play a strong factor also food allergies especially to milk and dairy (damp foods). The fact that so little is known about the underlying causes of the condition is frustrating for both the people living with the condition as well as the medical profession.

The treatment is dependent on the severity of each condition for mild conditions they can take a tablet orally, as a suppository or as an enema containing amino salicylate, this reduces inflammation. For more serious cases they can use steroids, these act more aggressively in reducing inflammation,  long term use of the steroids is not recommended for example in steroids used for over 12 weeks the patient will often suffer from osteoporosis, high blood pressure, diabetes, weight gain, glaucoma, muscle weakness. To minimize the risk of the steroids is to eat a balance diet with lots of calcium, drink minimal amounts of alcohol, exercise and stop smoking, then if these don't work then they will use immunosuppressant’s which take about 8 to 12 weeks to show an effect. These will reduce the body’s immune response to the infection, the draw back with this is that it is nonspecific, meaning that it will not only affect the colon but affect the whole body. This will make the body much more prone to infection and attack from any virus or bacteria; it also lowers the body’s red blood cell count making you prone to anemia.  The preferred immunosuppressant is azathioprine this causes the least amount of side effects in most people. The possible side effects are nausea, diarrhea, liver damage, anemia, increased risk of infection and bruising, long term use has been linked to cancer particularly skin cancer as it thins the skin. If the case is severe and leading to dehydration and severely impacting on the quality of life they can simple cut out the large intestine and the small intestine is rerouted so it will pass the waste from the body.

TCM Diagnosis : Blood in stool

Syndrome differentiation:

Sp qi def., Sp and KD yang def., dampness retention

Manifestations: Sp qi def. is shown through the symptoms of lassitude, diarrhea, low appetite and heaviness and the inability to control blood. Also the blood def. signs of floaters in eyes.

Sp yang def. also the poor appetite abdominal distension, preference for warmth and palpitation and the cold sweating of the four limbs which can produce the pins and needle sensation through the pre dominance of yin at night.

Kd yang def. shown by the early morning diarrhea the edema on the body and also the lassitude and the night sweating and salty/ savory flavour in the mouth.

Damp retention is shown by the heavy limbs and body and general lassitude, the tenesmus the diarrhea

Explanation:

The spleen transforms the ingested food and drink to extract qi from it, this is called nutritive qi, and this nutritive qi is the basis for the production of qi and blood. Once the nutritive qi is formed it is transported to the various organs of the body. The spleen also is involved in separating the useable fluids from the un-useable this requires warmth to aid the steaming and transformation and transportation function, so if the spleen isn't warm enough (yang def.) this fluid can remain stagnant and form dampness, phlegm or fluids accumulating under the skin resulting in edema. It is said that the spleen likes dryness this dryness can be easily be attacked from external dampness and can seriously be impaired by excessive cold drinks.

The spleen controls blood, its role is to keep the blood in the vessels, if the spleen is healthy it is said that it will circulate normally and stay in the vessels. If the spleen is deficient then the blood may spill out of the vessels and result in hemorrhages.  The spleen also plays an important role in the production of the blood. If the spleen is def. then it can result in blood def. signs and symptoms.

The spleen controls the muscles and the four limbs as it nourishes the muscles and tissues with its nutritive qi and blood, if the spleen is def. then the nutritive qi cannot be transported to the limbs, as a result the person may feel lassitude, weak muscles and in severe cases atrophy.  

The Kidney is often referred to as "the root of life" this is because they store the "essence", part of this essence is derived from the parents and established at conception. Like all the the other yin organs the kidneys have a yin and yang aspect. However the difference between this organ and the others is that the yin and yang aspect of the kidneys determines and is the foundation of all the yin and yang of all the other organs. So the kidney yin is the primary yin for the yin energies of the body in particular the liver, heart, and lungs and the kidney yang as the foundation of all the yang energies of the body in particular the spleen, lungs and heart. Kidney yin is the foundation for birth growth and development, and kidney yang the motive force of all physiological processes. Kidney yin provides the material substance for kidney yang and kidney yang provides the heat necessary for all the kidney functions.

One of the functions of the kidneys is to govern and transport the water and body fluids if this function is in balance there will be correct opening and closing of the urinary "gate" if kidney yang is def. it will result in "clear" profuse urine. If in excess then scanty dark urine. Kidney yang provides the spleen with the heat it needs to efficiently carry out its transforming and transporting fluids, the kidney also yang steams water to the lung keeping it moist and prevents it from drying out. 

The kidney opens in to the ears; the ears rely on balanced nourishment from the kidney and are therefore physiologically related. If the kidneys are weak then the hearing may be impaired.

The kidney also controls and opens and closes the lower orifices the front and the rear, although the large intestine is anatomically related to the anus if the kidney qi weak it may result in diarrhea and prolapse of the anus.

As heat is essential to the spleen for its transforming and transportation and separation function the kidney yang "fire" is paramount if this fire is weak or yang def. then the spleen cannot function and leads to diarrhea, tiredness, feeling of cold limbs and weak legs and over time will lead to damp retention.

Dampness is a yin pathogenic factor it doesn't only refer to damp weather conditions but also from living in damp living conditions. External often will have a rapid onset; dampness can be caught from wearing wet clothes sitting in damp places. It tends to affect the legs and settle in the pelvic region and injures yang. Sticky nature of dampness makes it difficult to get rid of and often becomes chronic. As dampness injures yang particularly spleen yang it encourages internal damp retention creating a vicious cycle and it becomes impossible to distinguish between the two.

Internal dampness arises from def. of spleen and sometimes kidneys. The onset of internal dampness is gradual rather than sudden, the tounge and pulse are also slightly different in exterior the tounge has a thicker and greasy coating and in internal the coating will be greasy but thinner coating. Dampness causes the heaviness, lassitude of the body and the tenusmus of the anus and impairs the water and body fluid circulation. As dampness is dirty and sticky in nature it can result in skin problems occasionally with fluid oozing out and difficult cases of eczema.

Treatment Principle: Strengthen Kd yang and middle jiao yang, eliminate dampness

Points and Therapies:

Dachangshu, shenshu, chengshan, ciliao, pi shu, yinlingquan.

(First time he had acupuncture so not to many points)

Explanation:  Dachangshu as this strengthens the large intestine, shenshu for the KD yang, cilio also

                         for KD yang, pi shu for the spleen and, Chengshan as it helps with hemaroids as we

                        weren’t sure at this stage. Yinlingquan for eliminate dampness.

Lifestyle advice: Avoid cold (drinks water and beer) try to have warm drinks particular ginger tea in the morning with some warm porridge for breakfast, try to eat lots more vegetables lightly steamed, eat meat like lamb (warming) and avoid very greasy and spicy food. Also observe how he feels after eating dairy foods such as milk and cheese as he may have a dairy allergy. Try to so some easy exercise like walking. 

Conclusion: The following week he didn’t suffer from any more blood in the stools but they were still loose and four times per day. I have treated him another 5 times  since using mainly front mu points on my teachers recommendation (one time with back shu points), his condition has improved a lot, no bleeding and 2 times def. per day, no night sweats and much more general energy not so heavy feeling, also feels less phlegm in his ear. But in the last 3 weeks he has got quite sick with vomiting as a result of excess phlegm running done his throat in the morning. He has said that he feels the back shu points make him feel like he has more energy after treatment so I will try these again plus some extra points.

Irregular Menstruation for 2 years

Date of first visit: 11/10/2011                                      Name: Merry

Gender: Female                                                         Date of birth: 12/10/1972

Chief complains:  Irregular Menstruation for 2 years

Descriptions (4 diagnostic methods)

A: Asking

Present illness complains: Kay has a busy life. The menstruation became irregular about 2 years ago. There was plenty of bleeding in the beginning even though the timing was not regular. Now the timing is not regular and the bleeding is scanty and dark. There are some clots in the blood. Feel fatigue and sleepy all the time. Always feel cold, prefer warm drink. Urination and defecation are normal. Sore waist. 

Past history: Nothing abnormal detected

Lifestyle: working in a stressful environment

Family history: no

Menstruation, marital & obstetrical history: Single, no child,

The first period started at 12 years old.

B: Inspection

General: Lack of vitality, pale complexion

Others:

Tongue: pale and tender tongue body with thin white tongue coating

C: Auscultation/Olfaction

Sound: weak

Odours: nothing abnormal detected

D: Palpation

Body areas: cold in lower abdominal area

Pulse: weak and thready

Case Summary

Diagnosis: Irregular Menstruation

Syndrome Differentiation: Cold in Blood and blood deficiency

Explanation: She always feels cold, tired and sleepy, sometimes dizziness. Her pulse is weak, deep, and thready. Because of her busy life, she always goes to bed after mid-night, which is the important time for generating blood. Long term blood deficiency leads to dizziness and scanty menses. The blood circulation becomes slow and weak due to the deficiency of blood. Cold was accumulated gradually in the blood and due to the deficiency.       

Treatment principles: Points of the thoroughfare Vessel and Spleen Meridian are mainly prescribed. Acupuncture with even technique is appropriate to predated menstruation while needling and moxibustion are both recommended to the postdated menstruation and irregular menstrual cycle.

Points and Therapies: Qihai (CV6), and Sanyinjiao(SP6), Xueihai(SP10), and Guilai(ST29)

Explanations:

The points in this prescription are mainly for regulating Thoroughfare Vessel and Conception Vessel and activating the circulation of Qi and blood, as Conception Vessel is responsible for the conception and the vigorousness of Qi in Conception Vessel is essential to the normal menstruation. Qihai benefits the source of the whole body, therefore the abundant Qi is able to control blood, for Qi is the commander of blood, spleen and stomach form the foundation of generating blood, so Sanyinjiao is elected to build up spleen so that the blood is under control. Xuehai, Guilai, and Qihai are punctured with reducing technique to animate the circulation of Qi and blood for the postdated menstruation resulting from blood stagnation while the performance of reinforcing technique and Moxibustion in these points warms meridians and nourishes blood for blood deficiency.

Life style advice:

1. Raw, cold, or spicy food is prohibited,
2. Excessive physical labour or exercise should be reduced.
3. Have less stress life style
4. Have healthy diet and regular life style (i.e. go to bed before 10:30 pm)

 

TCM Etiology and Pathology:  

      Definition:  Irregular menstruation refers to the disorder of menses in their circle and is often accompanied by the morbid changes of the colour, amount, and the quality of menses blood. The menses is sometimes preceded and sometimes delayed. The common conditions of irregular menstruation are predated and postdated menstruation and irregular menstrual cycle. It is often found in menstrual disorders due to hypophyseal or ovarian dysfunction.  

          1.  Predated Menstruation :

               It is mainly caused by fire transformed from long-standing Qi stagnation due to mental           depression or worrying, or by the accumulation of heat in uterus so that the fire 

               or heat  makes the blood unsettles, thus the antedated cycle results. 

         2. Postdated Menstruation

              It resules chiefly from retention of pathogenic cold  in the uterus, or from feebleness

              of Yang and deficiency of blood which inactivate the flow in Thoroughfare Vessel 

              and  Conception Vessel, so the menstrual bleeding fails to come on due time.  

         3. Irregular Menstrual Cycle

  Multiparity, too much sex, chronic haemorrhagic, diseases, and constitutional

  weakness  of spleen and stomach undermining the liver and kidney, cause

  dysfunction  of Thoroughfare and Conception Vessels,  therefore, the menstrual

   flow is disordered and the cycle certainly become irregular.

Differentiation

1. Predated Menstruation

Blood Heat

Main Manifestations: Predated menstruation with large amount of sticky, condensed and purplish-red blood, irritability, stuffiness in chest, short and dark urine, red tongue and yellow coating, and rapid forceful pulse.

Qi Defficiency

Main Manifestation

Antedated menstruation which is thin, light red and in large quantity is associated with lassitude, palpitation, shortness of breath, feeling of emptiness and dragging-down in the lower abdomen, pale tongue, thin coating, and weak pulse.

    
     2. Postdated Menstruation

Blood Deficiency

Main Manifestation: Postdated menses is scanty, light red and accompanied by empty pain in the lower abdomen, emaciation, sallow complexion, lustreless skin, dizziness blurred vision, palpitation, insomnia, light red tongue with little coating, and weak, thready pulse.

Cold in Blood

Main Manifestation: Delayed menstruation in dark colour and small quantity is associated with colic in lower abdomen which is alleviated by warmth, cold extremities, aversion to cold, thin white tongue coating and deep, slow pulse.

Qi Stagnation

Main Manifestation: Postdated menstruation with dark and scanty coatingis accompanied by fullness and distending pain in lower abdomen, emotional depression, stuffiness in chest which is eased by eructation, distention in the costal region and breasts, thin and white tongue coating and wiry pulse.

     
     3.  Irregular Menstrual Cycle

Liver Qi Stagnation

Main Manifestation: Variance of menstrual cycle with sticky, thick and purplish bleeding which is impeded and in varying quantity, distention in costal region and breast, distending pain in lower abdomen, mental depression, frequent sighing, thin and white tongue coating and wiry pulse.

Kidney Deficiency

Main Manifestations: Irregular cycle with scanty, thin and light red blood flow, dizziness, tinnitus, soreness in lower back, weakness of knee, nocturia, loose stools, pale tongue with thin coating, and deep, weak pulse.

WMS:

Definition

The menstrual cycle is not the same for every woman. On average, menstrual flow occurs every 28 days (with most women having cycles between 24 and 34 days), and lasts about 4 days. However, there is wide variation in timing and duration that is still considered normal, especially if your periods began within the last few years.

If you soak through a sanitary pad or tampon every hour for 6 consecutive hours, this is considered a very heavy period. A prolonged period is one that lasts longer than 7 days.

A small percentage of women have periods more often than every 21 days or less often than every 35 days. These variations may be normal.

Causes

Causes of the metrorrhagia irregular menses pattern are unknown or are more likely related to stresses and ingested medications or substances that disrupt corpus luteum function or even act as anticoagulant blood thinners. Caffeine may act this way and disrupt corpus luteum function. Heavy caffeine consumers tend to have twice the risk of short cycle length (less than 24 days). Their cycles are not heavier but they are often more frequent.

Cigarette smoking is another agent that can shorten menstrual cycles. Cigarettes seem to shorten the follicular phase but heavier smoking also may shorten the luteal phase. Both heavy smoking and even smoking just 10 cigarettes or more a day may cause menstrual cycles to be shorter in length, as well as more variable in their lengths than nonsmokers.

Acute or excessive alcohol ingestion, getting drunk on occasion, is also known to alter menstrual patterns. Sometimes it shortens cycles while at other times it can cause a delay of menses. The alcohol is thought to affect the liver's ability to properly metabolize estrogen and progesterone.

Stress or eating disorders is also the most common cause. Recreational running does not seem to change menstrual cycle length, but strenuous endurance running can disturb cycle length, and make a woman anovulatory. Long distance runners and other strenuous sports have been well known to cause anovulation of the low estrogen type.

While the most common cause of irregular delayed menses is due to stress type hypothalamic amenorrhea, the next most frequent type is due to polycystic ovarian syndrome. This is a complex condition of the ovaries in which follicles seem to grow and produce estrogen but the egg does not get released. This results in a high estrogen condition but infrequent menses. When the period does start, it often can be a very heavy one that persists for days or even weeks. The continuous, high estrogens cause the uterine lining to grow and proliferate and eventually it gets too thick and then sloughs off causing a menstrual like bleed. Because of the chronic and continuous estrogen stimulation, most doctors feel that a menstrual period should be induced with hormones (progesterone/progestin) so that a woman is not at risk for endometrial cancer.

Women who have polycystic ovarian syndrome (PCOS) will frequently have abnormal carbohydrate metabolism called insulin resistance or even develop diabetes. Additionally, excess hair growth due to extra testosterone occurs in many women with PCOS.

Treatment

What is the best non-prescription treatment to make menses more regular?

For a metrorrhagia type of irregular menstrual pattern, it is important to give up tobacco, alcohol and cut caffeine servings down to 2 or less per day. Try to minimize any medications that you do not have to take. If menses are mildly irregular and you are trying to time conception, taking a phytoestrogen supplement on a daily basis may help stabilize the menstrual cycle length.

For a low estrogen, irregular menstrual problem, the key treatments are:

• stress reduction and/or relaxation techniques
• elimination of overly strenuous physical exercise
• eliminate any eating disorders such as purging, bulimia, or anorexia
• take supplemental, measured estrogens such as phytoestrogens in soy or clover products

For a high estrogen irregular menses pattern such as that found in PCOS, weight reduction using a low carbohydrate diet is essential. Even a 10% weight loss will help restore normal menstrual patterns in obese women who are anovulatory.

The supplements recommended below have been studied in clinical trials and have been found to be effective in connection with irregular periods. For best results you should take them over a period of three months, at the end of which you should be reassessed in order to monitor improvements and changes and then adjust the supplement programme according to your new condition.

Multivitamin and Mineral
A good quality multivitamin and mineral would form the foundation of your supplement programme to make sure that you are getting a 'little bit of everything'. You then add in those nutrients in slightly higher amounts which are known to be helpful for irregular periods.

B Vitamins
These are often called the 'stress' vitamins because they can help you to cope with the pressures of everyday life. As stress can be such an important factor in causing irregular periods it is important that you have some help in dealing with it. Vitamins B2, B3 and B6 are also necessary for thyroid hormone production and B5 (pantothenic acid) is essential for optimum adrenal function. Both imbalances in thyroid function and stress can affect your cycle.

The easiest way to make sure you are getting a good supply of these vitamins is to take them in the form of a good B-complex tablet. B vitamins are synergistic, which means that they work together.

Antioxidants
Antioxidants are particularly relevant with irregular periods. It is believed that antioxidants have the ability to prevent cells from mutating. In other words, they prevent cells from becoming 'abnormal'. This is extremely important if you have been diagnosed with thickening of the womb lining (endometrial hyperplasia) because you don't want the cells to mutate. Antioxidants include vitamins A, C and E and the mineral selenium. Their effects have been proven: women with womb tumours have been shown to have less of both selenium and vitamin E than women without them so make sure you are getting enough of these valuable nutrients.

Magnesium
This mineral has been classed as 'nature's tranquilliser', so it is an essential inclusion in the diet of anyone suffering from irregular periods. In fact, anyone in today's hectic society will benefit from a magnesium supplement. Stress is often a factor in period irregularity, and this mineral will help to redress the balance of a stressful lifestyle.

Essential Fatty Acids (EFAs)
Linseeds, which are an excellent form of both Omega-3 and Omega-6 fatty acids, have been proven to encourage regularity of the cycle among other things. Even if hormonal imbalance is not at the root of your condition, it is worth adding these fatty acids to your diet. There are many factors that are now known to affect the way fatty acids are used by our bodies, including high adrenaline levels (in the case of stress), high alcohol consumption, and high levels of cholesterol. If your body is NOT getting or using enough of the fatty acids consumed, your cycle can be affected. You can't lose by adding these supplements to your diet.

What are the best prescription treatments for menstrual irregularities?

Oral contraceptives (OCPs) are the most commonly used hormonal treatment for irregular menses. They do not correct the underlying problem that causes the irregularity but they will regulate the pattern very precisely to the same day of the week each cycle. In general, oral contraceptives are very safe and will not cause an alteration in the body even after taking for a very long time. Some women cannot take birth control pills, however, so other treatments are also used.

Women with irregular menses due to hypothalamic factors can take a sequential hormone regimen. In this regimen, estrogen is given each day and then progesterone is given for 10-14 days each month in order to induce a withdrawal bleed. This regimen will not protect against pregnancy should ovulation occur so if a pregnancy is desired, this may be the best regimen.

For polycystic ovarian syndrome most physicians will prescribe oral progestins or progesterone to take for 10 days every two months if there has not been a spontaneous menses. This is thought to protect against the development of endometrial cancer or hyperplasia from the long term elevation of estrogens.

Carbohydrate metabolism abnormalities are often successfully treated with a combination of diet and medications, and the menstrual irregularities may disappear. Metformin, a drug which reduces high insulin levels has been shown to make women with PCOS resume normal menses in almost 90% of cases . This is a dramatic breakthrough in treatment and one worth seeing your physician about if you have PCOS.

 

 

Follow up consultation

 

 

Patient Name: Merry                                                              Treatment Number:2

TCM Disease: Irregular Menstruation                                     Date: 18 / 10 /  2011

Current condition/ changes:

The patient feels more energetic, but the MC still not comes yet. She still feel cold, but not as cold as before.

Treatment Principle:

Expel the cold and promote the circulation of QI and Blood

Prescription:

Keep the same needling points: Qihai (CV6), and Sanyinjiao(SP6), Xueihai(SP10), and Guilai(ST29)
Moxa the above points after needling
 
Use ear acupuncture on the points related to Intertragus, Ovary, Uterus, Kidney, and Liver.

Explanation (if any adjustment):

The patient can only come once a week. Use ear acupuncture can help the performance of treatment.

Lifestyle Advice (if any adjustment):

Same with the first visit.

Case Conclusion

This is a chronic disease. It takes time to rebuilt a healthy constitution with energetic Qi and Blood. Some tonic herbs might be helpful to strengthen the QI and Blood of the patient and improve the effect of treatment.