Right hand pain for 2 weeks

Record of First Visit

Date of first visit:	9-Mar-2009
Name:	ABC
Gender:	Male
Age:	22

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Chief complaint: Right hand pain for 2 weeks

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Description (4 diagnosis method)

A: Asking

Present complaint:	He has been suffering from right hand pain for 2 weeks. The right hand knuckles accidently has been injured 2 weeks ago. When he was washing his hand, the right knuckle hit the water tap hardly. The pain is mainly on knuckles but it spread to on the whole right hand. The movement of hand is not comfortable. Pain type – dull pain. Pressing makes the pain worse. The wrist also has some pain when it is used for a long time. Appetite - normal Urination - normal Defecation – normal, sometimes loose stool Sleeping -normal No thirsty – prefer cold water
Past history:	NAD
Lifestyle:	Late sleep – goes to bed 2~3 am
Family history:	Parents – alive – healthy 1 sister - healthy
Menstruation:	NAD
Marital&obste-trical history:	Single

B: Inspection:

General:	Vitality
Other:	NAD
Tongue:	Tongue body - red and purplish Tongue coating – white and thin coating.

C: Auscultation/Olfaction

Sound:	NAD
Odours:	NAD

D: Palpation:

Body area:	NAD
Pulse:	Taut and thready

CASE SUMMARY

TCM Diagnosis: Right hand pain

Syndrome Differentiation: Blood stasis and qi stagnation in local area

Explanation:

The patient has been suffering from right hand pain. The pain was caused by injury 2 weeks ago from the first consultation. The pain is mainly on knuckles but it spread to on the whole right hand. The movement of hand is not comfortable. Pain type was dull pain. The pressing makes the pain worse. The wrist also has some pain when it is used for a long time.

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.

The symptoms are manifested by pain, swollen, and movement limitation in local area.

Treatment Principles:

Remove qi blockage and blood stagnation.

Promote Qi and blood circulation.

Relieve pain.

Points and Therapies:

Baxie (Ex-LE-9)

Yangxi (LI 5)

Waiguan (SJ 5)

Explanation:

Baxie (Ex-LE-9)	Relaxes muscles and tendons Benefits for finger joints disorder
Yangxi (LI 5)	Benefits for the wrist pain
Waiguan (SJ 5)	Promote qi and blood circulation

THEORY

TCM:

Srain

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

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WMS: Sprain

The word sprain comes from the French espraindre, which means "to wring." A sprain is damage to a ligament from excessive stretching forces. Articular ligaments are thick, semi-elastic connective tissues that connect bone to bone. The function of the ligament is to stabilize the joint and prevent movement of bones in certain directions. For example, the knuckles of the fingers are hinge joints, and interphalangeal ligaments help restrict hyperextension.

Sprains are classified as grades I, II, and III, corresponding to mild, moderate, and severe injuries. A patient may not seek medical attention for a grade I sprain because the injury is only a stretching of the ligamentous fibers, and the child may feel only mild discomfort with minimal-to-no functional loss. With a grade II sprain, ligaments are partially torn. Tenderness, swelling, and sometimes ecchymosis are present, with mild-to-moderate functional loss. A ligament is completely torn in a grade III sprain, leaving the affected joint unstable, with significant and diffuse tenderness, ecchymosis, and swelling.

It is characterized by pain and weakness over the knuckle of the hand due to injury of the tendons that straighten the joints of a finger. The extensor tendon attaches the forearm muscle to the bone that straightens the fingers. This injury involves a tear of the tendon or the tissues that hold the tendon in position. It results in a tear of the extensor tendon, the tissues that help hold the tendon in place, and occasionally injury to the tissue that surrounds the knuckle joint. This condition usually heals with splinting or surgery.

Complications include: an inability to straighten finger, finger stiffness, tendon rupture prolonged healing time, if usual activities are resumed too soon, and recurrence of symptoms and/or repeated injury.

Common Signs and Symptoms

• Pain and tenderness over the injured knuckle
• Weakness or inability to completely straighten the finger under its own power
• Full passive motion of the finger (can be straightened)
• Swelling and warmth of the injured finger over the knuckle

Risks

• Sports that involve contact or hitting with the hand, such as boxing or martial arts
• Poor physical conditioning (strength and flexibility)
• Previous or concurrent injury to the knuckle
• Previous or untreated knuckle sprain

Treatment

Initial treatment involves splinting, icing and elevation to reduce swelling. Medications may be given for pain. If splinting is the treatment, this is for variable periods. Often, surgery is recommended to repair the injured tissues. After surgery, the joint is immobilized with a cast, brace, or splint to allow the tissues to heal. After immobilization (with or without surgery), stretching and strengthening of the injured and weakened joint and surrounding muscles (due to the injury and the immobilization) is necessary. This may be done with or without the assistance of an occupational or physical therapist or athletic trainer. Return to punching is allowed after full range of motion and normal strength are achieved, usually after 4 months.

Follow up Consultations

Treatment Number:	2
Patient Name:	ABC
TCM Disease:	Right hand pain
TCM Type:	Blood stasis and qi stagnation in local area
Date:	16/Mar/2009
Age:	22
Current condition/ change:	The pain symptom has got better. The movement is more comfortable.
Treatment Adjustment:	Add Zusanli and Sanyinjiao
Explanation: (If any adjustment)	The points of Zusanli and Sanyinjiao are added to promote more Qi and blood.
Lifestyle Advice: (If any adjustment)

Treatment Number:	3
Patient Name:	ABC
TCM Disease:	Right hand pain
TCM Type:	Blood stasis and qi stagnation in local area
Date:	23/Mar/2009
Age:	22
Current condition/ change:	The pain symptom has gone almost. The movement is more comfortable.
Treatment Adjustment:	Add Zhongwan and Shangwan
Explanation: (If any adjustment)	The points of Zhongwan and Shangwan are added to promote more Qi and blood.
Lifestyle Advice: (If any adjustment)

Treatment Number:	4 (Final) – case closed
Patient Name:	ABC
TCM Disease:	Right hand pain
TCM Type:	Blood stasis and qi stagnation in local area
Date:	6/Apr/2009
Age:	22
Current condition/ change:	A little bit stiffness feeling around knuckle. Whole body tiredness.
Treatment Adjustment:	Add Qihai and Guanyuan
Explanation: (If any adjustment)	The points of Qihai and Guanyuan are added to promote more Qi and blood.
Lifestyle Advice: (If any adjustment)

Case Conclusion

The patient has been suffering from right hand pain. The pain was caused by injury 2 weeks ago from the first consultation. The pain is mainly on knuckles but it spread to on the whole right hand. The movement of hand is not comfortable. Pain type was dull pain. The pressing makes the pain worse.

The wrist also has some pain when it is used for a long time.

All together 5 treatments were done and the case was closed.

For the first treatment, the local points Baxie (Ex-LE-9), Yangxi (LI 5), and Waiguan (SJ 5) were treated in order to promote Qi and blood circulation and relieve pain. The symptoms were relieved after one treatment.

And second, third and fourth treatments were done around one week intervals. Two more local points were added in every follow-up treatment to promote more Qi and blood circulation. The symptoms got better except for the final treatment. On the final treatment day the patient complained the whole body tiredness as well. It could be the reason of it.

After all the treatment the trust feeling between the patient and me were established.

The patient said he would come back when he was sick.

I feel confident and I would use the similar treatment to the patient who shows the similar symptoms.

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Cold tummy for 2years

Date of first visit: 3, March 2009

Name: S Date of Birth 28 June78 Gender: Female

Address & Contact No. : OO

Chief complaints

Cold tummy for 2years

Descriptions (4 diagnostic methods)

A: Asking

Current condition	The patient is complaining of cold tummy that has been for 2years. Sometimes the cold sensation goes to lower limbs, heavy feeling in lower jiao, cold feet. Relieved by warmth and right pressure, Dreaminess, Extremely low energy during period. Appetite and drink-normal, defecation and urination-normal
Past history	NAD
Life style	Normal
Family history	Father has diabetes, mother has knee pain
Menstruation	Menarche at15, 30 days cycle and 4-5days, last month period 16th Feb.

B: Inspection

General	Tall and robust build, vitality 8/10
Others	NAD
Tongue	Pale pink, swollen tongue body, thick white coating

C: Auscultation/ Olfaction

Sound	NAD
Odour	NAD

D: Palpation

Body area	NAD
Pulse	Moderate, taut, weak(qi)

Case Summary

TCM Diagnose: Coldness in lower jiao

TCM Type/pattern: Spleen qi(yang) deficiency and Kidney yang deficiency

Explanation:

Therapeutic principle: Tonify Spleen and kidney. Warm general body.

Points selected:

Pishu, Shenshu, Mingmen, Zhongwan, Qi hai, Guan yuan, Zusanli/combined with moxa treatment

TCM

SP Yang Deficiency

* General Signs & Symptoms:

A further progression of SP Qi Deficiency above with more cold signs, cold limbs, chilliness, edema (more in the middle wawrmer)

* Tongue:

Pale, wet, swollen w/teethmarks

* Pulse:

Deep

* General Treatment Points:

* Maciocia Treatment Points w/Valaskatagis commentary, modifications and additions

* Same points as SP Qi Deficiency but you would use moxa and add the following points to further tonify the SP

* SP 9 - resolve dampness

* CV 9 - resolve dampness in the middle warmer

* ST 28 - resolve dampness in the lower warmer

UB 22 - TH Shu, effect fluids in the lower and middle warmers

SP Qi Deficiency

* General Signs & Symptoms:

Poor appetite, distention after eating, weakness of the four limbs, fatigue, loose stools

*Tongue:

Pale, swollen w/teethmarks

* Pulse: Empty

* General Treatment Points:

* Maciocia Treatment Points w/Valaskatagis commentary, modifications and additions

* CV 12 - ST Mu, distention after eating

* ST 36 - tonify ST/SP

* SP 6 - tonify SP Qi

* SP 3 - best with dampness in the channels, could leave this out

* UB 20 - SP Shu

* UB 21 - ST Shu

KD Yang Deficiency

* General Signs & Symptoms:

Sore a/or weak back/knees, sensation of cold, aversion to cold, weak lower limbs, lassitude, clear copious urine, poor appetite, loose stools, edema (which can be severe)

* Tongue:

Pale, swollen, wet possibly a white coat with strong water signs

* Pulse:

Deep, weak possibly slow with strong water signs

* General Treatment Points:

* Maciocia Treatment Points w/Valaskatagis commentary, modifications and additions

* UB 23 - KD Shu

* GV 4 - tonify Yang

* CV 4 - tonify Yang

* CV 6 - tonify Qi

* KD 3 - tonify KD

* KD 7 - tonify KD Yang

* UB 52 - tonify KD, strengthen willpower

* For strong water signs consider the following:

* UB 13 - LU Shu

* UB 15 - HT Shu

* UB 20 - SP Shu

* UB 22 - TH Shu, major point for water regulation

* ST 28 - move fluids in the lower warmer

* SP 9 - resolve dampness

* LU 7 - upper body edema

Follow up and life style

-Exercise recommended

-Sleep early and get up early

-Have and drink warm property food and drink

WMS

Cold sensitivity or cold intolerance is unusual discomfort felt by some people when in a cool environment.

There is much variation in the sensitivity to cold experienced by different people, with some putting on many layers of clothing while others in the same environment feel comfortable in one layer.

Cold sensitivity may be a symptom of hypothyroidism, anemia, or vasoconstriction (according to article Sauna). There may also be differences in people in the expression of uncoupling proteins, thus affecting their amount of thermogenesis.

It has been found that one's state of mind influences one's perception of ambient temperature. Thinking about an incident where one felt excluded caused experimental subjects to estimate the ambient temperature 3 degrees Celsius lower than subjects who thought about experiences in which they felt included.

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Shoulder pain for several years

Date of first visit: Mar 16, 2009

Name: Mrs Age: 67yrs Gender:Female

Address & Contact No. :

Chief complaints

Shoulder pain for several years

Descriptions (4 diagnostic methods)

A: Asking

Current condition	There was no injury happened. She doesn’t remember when the pain started. The pain is always there. Massaging the area with hot water makes her feel better. Her appetite is not bad and eats quite a lot. She likes spicy food and doesn’t drink water too much. She has no problem with urination because she had an operation for frequent urination 10 years ago. She has a normal defecation. Normally she goes to bed at 12 and wakes up at 5 but she is difficult to go to sleep and easy to wake up. She wakes up often during the night and has a lot of dreams. She has no sweating, aversion to cold and cold in 4 limbs. Low back pain
Past history	She has an inflammation in ST and took a medicine 2 years ago.
Life style	Pensiveness, worry, angry. Her husband is sick and lives in a rest house. Her family is in Korea and lives alone now Playing golf regularly
Family history	Mum and granddad with hypertension
Menstruation	NAD

B: Inspection

General	Short and thin, vitality 6/10
Others	NAD
Tongue	Teeth marks, thin white coating

C: Auscultation/ Olfaction

Sound	Tinnitus on the right ear for 4~5years
Odour	NAD

D: Palpation

Body area	NAD
Pulse	Slippery

Case Summary

Definition: Pain in the shoulder which may be aching, dull, or stabbing in character. In the case of a sudden occurrence, the pain may be severe with the upper arm and the elbow involved.

There is atrophy of the muscles in the shoulder with more than two sensitive tender points. For instance, under the acromian or in the anterior part of the shoulder.

Both active and passive movements of the shoulder joint are limited, especially abduction, external rotation and elevation.

WMS

Description: What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion to the arm, from scratching your back to throwing the perfect pitch. Mobility has its price, however. It may lead to increasing problems with instability or impingement of soft tissue resulting in pain. You may feel pain only when the shoulder is moved, or all of the time. The pain may be temporary and disappear in a short time, or it may continue and require medical diagnosis and treatment.

Causes: A common cause of shoulder pain is soreness of the tendon (a cord that attaches a muscle to a bone) of the rotator cuff (the part of the shoulder that helps circular motion). Another common cause is soreness of the subacromial bursa (a sac of fluid under the highest part of the shoulder). You might experience soreness after activities such as painting, lifting or playing a sport, which require you to lift

your arms. Or you may not remember any specific injury.

The main joint in the shoulder is formed by the arm bone and the shoulder blade. The joint socket is shallow, allowing a wide range of motion in the arm. The rotator cuff is made up of 4 muscles that surround the arm bone. This cuff keeps the shoulder steady as the arm moves.

Teatment: Treatment generally involves altering activities, rest and physical therapy to help you improve shoulder strength and flexibility. Medication may be prescribed to reduce inflammation and reduce pain. If medication is prescribed to relieve pain, it should be taken only as directed. Injections of drugs may also be used to treat pain. Surgery may be required to resolve shoulder problems; however, 90 percent of patients with shoulder pain will respond to simple treatment methods such as altering activities, rest, exercise and medication. Certain types of shoulder problems, such as recurring dislocation and some rotator cuff tears may require surgery. Common sense solutions such as avoiding overexertion or overdoing activities in which you normally don't participate can help to prevent shoulder pain.

TCM

Etology & Pathology

1.Wind-cold : Acute pain in the shoulder joint that is aggravated by exposure to cold and application of het, a feeling of cold

2.Damp-cold : Ache in the shoulder region that may extend to the scapula region, a feeling of heaviness, numbness, coldness on palpation.

3.Stagnation of Qi and stasis of Blood : Pain in the shoulder joint, rigidity of the shoulder, a feeling of distention

TCM diagnosis : Shoulder pain

Syndrome differentiation : Qi and Blood stasis underlying SP and KD Yang deficiency.

Explanation:

She has the symptoms of KD yang deficiency, marked by low back pain, tinnitus and cold in 4 limbs.

KD yang is primary yang so it could affect SP yang deficiency and she has the symptoms of SP yang qi deficiency, marked by teeth marks ,being tired all the time and aversion to cold.

SP deficiency causes the poor function of transformation and transportation and the reason of the pain in the shoulder area is the SP deficiency.

Treatment principle:

1. Circulate the Qi and Blood on the local area

2. Tonify SP and KD yang

Treatment Points and their roles:

1. Bingfeng, Naoshe, Tianshong : as local points

2. Houxi : as a distal point

3. Mingmen : Supports the LR, tonifies blood and KD and expels wind

4. Shenshu : tonifies and harmonises the KDs and strengthen the loins and benefits the ears and eyes.

5. Pishu : tonifies and harmonises the SP

Life style advice

1. Keep doing exercise, but walking instead of golf.

2. Massage the area gently for the good circulation of Qi and Blood.

3. Try to free from stress and worry by making friendship.

4. Treat Insomnia. (advised her to have an acupuncture treatment for that)

Follow up

1. First follow up at Mar 19, 2009

Not much changed. Taking the points as same as before

2. Second follow up at Mar 23, 2009

The shoulder pain has much improved, but Tinnitus is getting worse on the right.

Points : + Tinghui and Taixi.

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Chronic cough for 3 years

Date of first visit: 05/3/2009

Name: Mr Mike Lee Gender: male Date of birth: 1/2/1959

Chief complaints: Chronic cough for 3 years

Description (4 diagnostic methods)

A. Asking

Present illness complaints: Mr Lee is 50 years of old. He has suffered from the chronic cough for 3 years. He was infected with a chronic cough from a person who had a cold. He has a cough on and off. He expectorates scanty and sticky phlegm occasionally. He has a tidal fever in the afternoon, itching throat but no sweating. He sleeps less time than average people’s but falls asleep immediately. He doesn’t separate cold or warm drinks. He has good appetite, normal defecation and yellowish urination. He took herb medicine for about forty days at the first time of the cough without western medication.

Past history: TB in the lung about 20 years ago and cured completely.

Lifestyle: Staying awake, alert status, pleasant, appreciates ecstatic beauty of nature, and busy

Family history: His father died of colonoma.

Marital history: Married with 2 children

B. Inspection

General: Vitality 9/10

Others: NAD

Tongue: Slightly red color with swollen, thin white coating

C. Auscultation/Olfaction

Sound: NAD

Odours: NAD

D. Palpation

Body areas: NAD

Pulse: thin and weak

CASE SUMMARY

Definition:

Chronic cough is usually defined as a cough lasting more than three weeks. Chronic cough is not a disease in itself; rather it is a symptom of other disorders.

WMS

Description:

Cough is a common presenting complaint in the frontline physician’s office, but in most patients the symptom is self limiting. In others, symptoms may persist from weeks to years and are associated with significant morbidity. Successful treatment depends on finding the cause and initiating specific therapy. The most common causes are cigarette smoking, asthma, post-nasal drip, GERD or post-viral respiratory tract infection. Multiple causes in the same patient are common. When the cough persists in spite of specific or empiric therapy and either the physician or the patient is dissatisfied with the diagnosis or treatment, referral to a specialist should be considered.

Causes:

(1) Cigarette smoking is the most common cause of chronic cough.

(2) Asthma; which is a disease of airways, resulting in difficulty breathing or wheezing.

(3) Postnasal drip and sinus problems; This condition can be difficult to detect. Sometimes CT scan of the sinuses is necessary for diagnosis.

(4) Gastroesophageal reflux disease (GERD); Some foods may increase reflux.

(5) Infections such as bronchitis or pneumonia; These infections can be caused by virus, bacteria or fungus.

Treatment

The treatment of cough is determined by the causes; Asthma – steroids and bronchodilators, GERD - selecting foods to take, Nasal or sinus problems – decongestants or antihistamines, Infections- antibiotics. However, patients may get symptomatic relief from over-the-counter cough medicines containing guaifenesin and/or dextromethorphan, drinking lots of water, inhaling steam, and using cough lozenges. In severe cases a doctor may prescribe codeine, which is an effective cough suppressant. It is very important to obtain a chest x-ray if a chronic cough is prolonged. For the minority of patients in whom this diagnostic approach is unsuccessful, consultation with a pulmonary specialist is appropriate.

TCM

(1) Invasion by the exogenous pathogenic factors

The lung dominates Qi and is regarded as an umbrella protecting the five Zang-organs. It governs respiration and associates with the skin and hair externally. Once the lung is attacked by the exogenous pathogenic factors the lung Qi is blocked and fails to descend, thus resulting in cough. The exogenous pathogenic factors attacking the lung is divided into two types: wind-cold and wind-heat.

(2) Internal injury

Cough resulted from functional impairment in the Zang-Fu organs, falls into the category of cough due to internal injury caused by deficiency of yin with dryness of the lung leading to failure of Qi of the lung to descend; and caused by the deficiency of the spleen which gives rise to internal dampness whose excessive accumulation produces phlegm.

SYNDROME DIFFERENTIATION: Internal injury

(1) Blockage of the lung by phlegm

Main manifestation: Cough with profuse, white and sticky sputum, stuffiness and chest congestion, loss of appetite, white, sticky tongue coating and rolling pulse.

(2) Deficiency of yin with dryness of the lung

Main manifestation: Dry cough without sputum or with scanty sputum, dryness of the nose and throat, sore throat, spotting blood or even coughing blood, afternoon fever, hot flush, red tongue, thin coating, rapid, and thready pulse.

TCM Diagnosis: Cough

Syndrome Differentiation: Lung yin deficiency (with dryness)

Explanation:

There are several manifestations of Lung yin deficiency (with dryness) such as scanty and sticky phlegm, a tidal fever in the afternoon, itching throat, red color tongue with swollen, thin white coating and thin and weak pulse. Some manifestations like cough, itching throat and thin white coating are relevant to wind-cold syndrome.

Treatment Principles:

Nourish yin. Eliminate dryness and descend lung qi.

Points, Therapies and Explanations:

Feishu BL13 & Zhonhfu LU1; To nourish lung yin and regulate lung qi

Lieque LU7; To be connect with conception vessel to descend lung qi and

relieve cough

Zhaohai KID6; Combining with Lieque to nourish yin and clear the throat.

Pishu BL20; To regulate the qi of middle jiao.

Dingchuan EX-BW1; To stop a cough

Life Style Advice

Do regular exercises to strengthen body

Take appropriate sleep and rest

Drink more water

Keep fresh and clean air environment

CASE CONCLUSION

The patient’s chief complaint is to have a chronic cough for three years. The diagnosis is Cough and the syndrome differentiation is Lung yin deficiency (with dryness). It results interior functional impairment in the lung leading to failure of Qi of the lung to descend which causes cough. The treatment principle is to nourish yin and to descend qi. The chosen points are Feishu BL13 , Zhonhfu LU1, Lieque LU7, Zhaohai KID6, Pishu BL20, and Dingchuan EX-BW1.

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