Date of First Visit: 29/02/2012                                             Name: Ms. R. J

Ages 43                                                                                Gender: female

Chief complaint: (L) shoulder pain for 5 days

The patient has left shoulder pain for 5 days.  She visited Singapore for a short time and returned here 5 days ago. When she woke up from 1st night sleep in NZ, she feels pain on bingfeng point area with dull pain and no limitation of movement.  When she was in Singapore, weather was very hot, but when she came back to NZ, she feels very cold.  

No chill & fever, good sleeping, normal defecation and urination, no thirst, normal drink. Prefer to warm water, no headache

Past illness history: nothing special detected

Life style: Busy, no smoking & alcohol

Family history:  healthy

Menstruation, marital & obstetrical history: 13, 5 / 28    normal amount & color, no pain, single

B) Inspection

General: Vitality 7-8/10, normal complexion & shape

Tongue: pink tongue, thin & white coating

C) Auscultation/Olfaction

Sound: speak clearly, normal breathing

Odors: Nothing abnormal detected

TCM diagnosis

A ) Diagnosis: Shoulder pain

B ) Syndrome Differentiation: Wind cold attack  

C) Explanation:

The patient has left shoulder pain caused after overseas trip in hot country. When she was back to NZ, she feels very cold. After short time overseas trip, she feel very tired and weak body couldn’t adjust sudden weather change. So, pathogenic wind evil entering the skin and invades channel. The wind is yang evil and tends to invade the barrier of skin and fight against defensive qi. When wind evil combines with cold evil, is shown pain. Cold evil is coagulating and obstructing. Thin & white coating and wiry pulse are manifestations marking wind cold evil. 

Treatment

A) Treatment principles:  Expel wind and dispel cold to release the pain

B) Treatment methods  /Needling: filiform Points:

     bingfeng (SI12), fengchi (GB20), fengmen (BL12)

      reducing method

C) Explanations:

• Bingfeng: local point. It activates the channel with Moxa to dispel cold and releases the pain
• Fengchi: a point at the intersection of gallbladder meridian and yang link vessel is used to  eliminate wind cold and relieve the exterior symptoms
• Fengmen: a point of bladder meridian, which dominate the surface of whole body      is selected to regulate circulation of qi, to eliminate wind cold
  

Life style advice

     Avoid wind and cold, keep warm shoulder area,

     Have regular exercise and stretching

     Not lift any heavy things

  

             Case Conclusion

This patient has left shoulder pain caused after overseas trip in hot country. When she was back to NZ, she feels very cold. After short time overseas trip, she feel very tired and weak body couldn’t adjust sudden weather change. Pathogenic wind evil attacks the skin and  channel. The wind is pertained yang evil and tends to invade the barrier of skin and fight against defensive qi. When wind evil combines with cold evil, is shown pain, Shoulder pain sudden onset by cold evil attack the superficial skin and cold nature is coagulating and obstructing the circulation qi and blood . So treatment principle focus on expel wind and dispel cold to release the pain. After first treatment, patient condition was back to normal.