Gender: male Date of birth: 65 yo
CHIEF COMPLAINT(S): Running nose for more than 10 years
DESCRIPTION (4 diagnostic methods):
Asking:
Present Illness History: The patient felt that his nose was blocked ten years ago when he got up in the morning. This happened without obvious reasons. No long later, he also found that he had difficulty to breathe and was running nose in the morning. It disappeared during daytime. Mucus accumulated in the upper part of the mouth, leading to hard to breathe and uncomfortable.
Present Symptoms: Mucus in the nose and blocking almost everyday when he wakes up in the morning. It disappears during daytime. The mucus is slightly thick and a bit yellow. He also feels bloated in abdominal area in the morning and relieved by belching. Good appetite, sometimes feels distention, prefers warm drink, no pain, no SOB, normal defecation, frequent urination.
History: Fell out of bus at age 3, landed on head; sinus for more than 30 years; tonsils and adenoids removed; appendix removed 25 years ago; hypertension on medication Accupril 20mg per day; enlarged prostate
Life style: Retired, no enough exercise, coffee drinker
Family history: Parents healthy
Menstruation, marital & obstetrical history/men’s sexual health:
Married with three kids
Inspection:
General: Normal size, fit, 8/10 vitality, moving properly
Tongue: Purple and watery tongue, with teeth marks, thin white coating
Auscultation/Olfaction:
Sound: Speak clearly, no SOB.
Odors: NAD
Palpation:
Body Area: NAD
Pulse: Slippery, slow, deep in chi
CASE SUMMARY
Definition:
Rhinorrhea, commonly known as a runny nose, consists of an unusually significant amount of nasal discharge. It is a symptom of the common cold and of allergies (hay fever) or dysfunction of lung.
TCM Etiology and Pathology:
1. Invasion of wind cold. The invasion of wind cold attacks the skin or lung, causing the lung dysfunction of dispersing. Mucus accumulates in the lung and airway. Mucus discharge from nose is the manifestation of wind cold or common cold.
2. Lung qi deficiency. The lung is weak and can not disperse properly. Mucus accumulates and leads to runny nose.
TCM Diagnosis: Runny Nose
Syndrome Differentiation: Lung qi deficiency
Explanation:
Lung opens to the nose and it is the container of phlegm. The patient has damp phlegm inside the body (especially in lungs) manifesting as slippery pulse and running nose. The patient is 65 years old, aging makes kidney function getting weaker showing deep and week pulse. Watery and purple tongue indicates yang qi deficiency and qi deficiency may lead to blood stasis.
Treatment principles: Tonify lung and strengthen qi
Points and therapies:
Shangxing (even), Yingtang (even), Taiyuan (+), Chize (+), Zusanli (+), Zhaohai (+)
Explanation:
Selecting filiform needles to dredge channels and activate collaterals. Shangxing is beneficial point to nose (Du channel point to activate channels and collaterals), Yingtang is the local point to dredge the channel and benefits the nose area. Taiyuan is the Yuan-Source point to tonify lung qi, Chize is the He-Sea point to strengthen lung function. Zusanli is the He-Sea point of St channel to tonify qi. Zhaohai is the confluent point of Yin-Heel vessel benefits the throat.
Lifestyle advices:
1. Keep warm and avoid cold attack.
2. Regular exercise, like Taichi, will help
FOLLOW UP CONSULTATION (2)
Patient Name: Rex Treatment Number: 2
Date: 31 / 10 / 2008
TCM Disease: Runny Nose
TCM type/pattern: Lung qi deficiency
Current condition/change:
Runny nose was getting better, less mucus when he woke up in the morning. He felt the blood circulation in the lower legs was improving (varicose veins).
Treatment Principle (if it is different): Points selection: Remove Zhaohai, add Sanyinjiao.
Explanation (if any adjustments):
Sanyinjiao is the local point to promote blood circulation
Lifestyle Advice (if any adjustments):
FOLLOW UP CONSULTATION (3)
Patient Name: Rex Treatment Number: 3
Date: 7 / 11 / 2008
TCM Disease: Runny Nose
TCM type/pattern: Lung qi deficiency
Current condition/change:
Running nose stayed in the improved level. Lower legs were feeling much more comfortable (varicose veins).
Treatment Principle (if it is different): Points selection: Same as last treatment, add Yingxiang.
Explanation (if any adjustments):
Yingxiang is the local point to activate the channels and collaterals to help the breathing, it benefits running nose.
Lifestyle Advice (if any adjustments):
FOLLOW UP CONSULTATION (4)
Patient Name: Rex Treatment Number: 4
Date: 21 / 11 / 2008
TCM Disease: Runny Nose
TCM type/pattern: Lung qi deficiency
Current condition/change:
Running nose improves a lot, just a little bit left in the morning. Lower legs circulation was feeling much better. Bloated stomach is the problem, it happens after breakfast.
Treatment Principle (if it is different): Points selection:
Same as last treatment, remove Sanyinjiao, add Zhongwan (+), Qihai(-)
Explanation (if any adjustments):
Zhongwan is the Front Mu point of stomach, combined with Zusanli to restore the function of Stomach (tonify). Qihai is the Sea of Qi, regulating qi (reducing) to induce the qi going downwards.
Lifestyle Advice (if any adjustments):
FOLLOW UP CONSULTATION (5)
Patient Name: Rex Treatment Number: 5
Date: 28 / 11 / 2008
TCM Disease: Runny Nose
TCM type/pattern: Lung qi deficiency
Current condition/change:
Running nose almost gone, bloated stomach was improving
Treatment Principle (if it is different): Points selection:
Same as last treatment, add Tianshu, Daheng, SHuifen, Shuidao, Fenglong.
Explanation (if any adjustments):
Tianshu is the front mu point of Large Intestine on stomach channel combined with Daheng to regulate stomach channel qi. Shuifen and Shuidao reduce the extra dampness. Fenglong is to reduce the phlegm.
Lifestyle Advice (if any adjustments):
CASE CONCLUSION
The requirements of Case Conclusion:
- Summarise your cases including your diagnosis, the procedure of treatment, and any changes of patients’ condition.
- Have you added different methods since first treatment? How do you develop your diagnostic and treatment skills?
- Would do you like to use those techniques and methods to treat other patients again?
- What do you learn from this case? What are the most important considerations?
The TCM disease is runny nose and pattern is lung qi deficiency. The patient has been suffering from running nose in the early morning when gets up from bed. He also felt bloated after breakfast everyday. He did not receive any treatment for this. And this is his first time to received acupuncture treatment. He started Taichi exercise a few weeks ago before he came to acupuncture. He felt he could accept this type of treatment even though he felt a bit nervous at the beginning. He gained more confidence after the first session. I add different points based on the symptoms he told me each time. It works very well in these five treatments. From this case I know the proper diagnosis is very important before the treatment. Collect the useful information and using the right acupoints is the key of better outcome. I will use this experience for the similar case in the future.
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