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.
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