Left wrist pain for one year

Date of first visit:	10-Dec-2011
Name:	Mr. D H
Gender:	Male
Age:	52

Chief complaint: Left wrist pain for one year

Description (4 diagnosis method)

A: Asking                      

  

Present complaint:	He complained about his left wrist stiffness feeling and pain.  The left hand accidently has been injured 1 year ago.When he fell over, he put his left hand to the ground. The stiffness feeling is always there and when he turns the wrist around, there is some pain. The movement of hand is not comfortable. Pain type – dull pain. Wet weather makes the pain worse. Warm massage makes the stiffness feeling better. Appetite - poor Urination - normal Defecation –loose stool Sleeping -normal No thirsty – drink warm and cold water
Past history:	NAD
Lifestyle:	Ordinary life style
Family history:	Parents – alive – healthy siblings - healthy
Menstruation:	NAD
Marital & obste-trical history:	Married with 1 child

B: Inspection:

                          

General:	Vitality 8/10.  Facial complexion – healthy   Body shape – middle height and chubby body looking Moving state – normal gesture
Other:	NAD
Tongue:	Tongue body - Pinkish Tongue coating – white and thin coating.

C: Auscultation/Olfaction

                                                   

Sound:	Voice – calm and peaceful voice Breathing – normal
Odours:	NAD

D: Palpation:

                                                   

Body area:	NAD
Pulse:	Left – weak & deep in general Right – weak & deep in general

 

                                                                                     

CASE SUMMARY

TCM Diagnosis: Left wrist pain

Syndrome Differentiation: qi and blood stagnation in local area underlying spleen qi deficiency.

Explanation:

He complained about his left wrist stiffness feeling and pain. The pain is caused by injury and the injury caused the blood stasis and qi stagnation. The blood stasis and qi stagnation is characterized by qi obstruction and blood obstruction. Also, he has poor appetite and loose stool symptoms which tells us he has spleen qi deficiency. Pinkish tongue body colour and weak pulse also support the deficiency symptoms.

Therefore the treatment principle is to remove qi blockage and blood stagnation, promote Qi and blood circulation and relieve pain. Tonifying spleen qi is added to the treatment principle in order to maximize treatment effect.

Treatment Principles:

• Remove qi blockage and blood stagnation.
• Promote Qi and blood circulation.
• Relieve pain.
• Tonify spleen qi.

Points and Therapies:

 

Daling (PC 7)	Relaxes muscles and tendons Benefits for wrist joints disorder
Yangxi (LI 5)	Benefits for the wrist pain
Waiguan (SJ 5)	Promote qi and blood circulation

  Zusanli (ST 36)          Tonify spleen, Tonify qi

  Sanyinjiao (SP 6)       Tonify spleen

TCM Theory:

Pathological change

*Laceration of membrane of tendon, ligament

*Over sprain, inflammation, degeneration

Diagnosis

*Injury / Over strain history

*Typical manifestation: pain, swelling, and tenderness, and limitation of movement

Differentiation

*Qi stagnation and blood stasis

Treatment principle

*Activate meridian.

*Dredge the collateral.

*Release swelling.

*Stop pain.  

Treatment

*Points = local + distal

Other method

*Ear acupuncture: Shenmen + corresponding points