2012年2月2日 星期四

Fatigue for one month


Follow   Up   Record

Treatment No:          2                                
Date:     26/01/2012                                 Time: 11:00 -11:40am (Wu-time)

Chief complaint: Fatigue for one month
Key points of patient condition:

He had got improvement well after first treatment; sleep hours around have 7 hours, from 10:30 pm to 6am.
Chest oppression: He still had some few signs in the morning, no any uncomfortable conditions such as radiate pain to upper back or tingling and numbness at medial side of forearm. No any medication at now.
Family history: father died (angina pectoris).  Old brother: hand trembling serious over 10 years

The Selected Healing Points:
Heaven/Earth needle (I-Ching acupuncture methods): To Balance yin/yang of body, to regulate and promote circulation of qi and blood
·         Zhongwan(+) with Moxa
·         Quanyuan(+) with Moxa
·         Tianshu(+)with Moxa

All Needle retaining time: 30 minutes                                                                                                    

Explanation:

The second treatment will follow up the first treatment principles to strengthen spleen/stomach function to generate qi and blood; this is very benefits for the patient to recovery. By using i-ching theory and apply to our treatment principle in order to Balance yin/yang of body, to regulate and promote circulation of qi and blood, this means activate qi flow can make blood, to stimulate congenital vital qi is quiet important method, any acquired disease or imbalance symptoms came from external pathogenic evil qi and internal emotion disharmony, further developing will cause our body function decline and sickness.

This patient had old ages (yang qi decreasing) and over consume energy (kidney and spleen yang) for a long time, because he had a job 3 months in Africa, The weather is too dryness and hot, it will impair our internal body fluid and qi step by step, lung yin deficiency can cause cough (lung qi rebelling), Regarded five elements theory, when lung qi (metal) insufficient also can affect spleen qi (earth) deficiency.

Trembling hand cause by liver wind upward due to liver blood deficiency, when spleen function decline it will fail to made new blood to nourish all body such as tendons, ligaments, blood vessels.

Chest oppression cause by heart yin insufficient fails to control heart qi, heart government Shen, dominate vessels when yin/yang imbalance, qi/blood disharmony can cause all body problems onset.

The patient always felt weakness, no energy, and tiredness. Our treatment principles focus on yin/yang balance first. To strengthen congenital vital qi and activate qi flow to move blood through whole body. When normal circulation of qi and blood leads to all nutrients can tonify internal organs this will have positive reflection in the future and strengthen our body resistance.

I-Ching acupuncture methods:

Heaven/Earth needle To Balance yin/yang of body, to regulate and promote circulation of qi and blood
·         Zhongwan(+) with Moxa
·         Quanyuan(+) with Moxa

Time: 11:00 -11:40am
·         Tianshu(+)with Moxa   Right side only

Wu time belongs to shaoyin heart meridian of hand, belongs to fire (five elements), it should be selected by fire can generate earth (middle jiao) to make sufficient qi and blood.

All Needle retaining time: 30 minutes 

The lifestyle advice according to Chinese medicine:
·         Take appropriate sleep and rest, including meditation 20 minutes per day
·         Avoid intaking from cold nature of foods and drinks, cafe , alcohol
·         Take herbal medicine to nourish yin if possible

2012年1月30日 星期一

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