Patient Last Name: S Patient First Name: J
Treatment Date and Time: . May 12, 2001
Sex and Age: Male 48 Profession: Artist
1. Chief Complaint: Indigestion and Stomach Pain for 15 years
2. Medical History:
Present Illness: The patient has suffered from indigestion and stomach pain for 15 years (beginning around the same time as his divorce). He is frequently hungry and feels good initially after eating, but begins to experience discomfort beginning an hour and ½ after meals. He experiences indigestion, which he initially described as a burning chest and epigastric pain that was most pronounced at Ren 12 and followed upward along the Ren channel behind his sternum and radiated down his shoulder and the posterior aspect of his left arm to about Ht 2 level. Now, the burning quality has subsided and the pain is milder and achy. The pain is worse with pressure and feels better after belching. He also experiences frequent acid regurgitation with a bitter taste (especially in the morning), bad breath and often has gas and abdominal distension. The patient feels that his digestion is slow – a condition that seems to be exacerbated by medication (Prilosec) for H. pylori, which he has had before. The patient also has chronic tightness in his chest, which is worse with stress. He has discovered that the tightness is somewhat relieved when he relaxes and makes an effort to “open” the area. His cardiologist has ruled out any new cardiac problems although the patient suffered a mild MI in December ’98 and becomes very nervous about any symptoms that may indicate heart problems.
Until recently, the patient suffered from irregular bowel movements, alternating between constipation with bleeding and diarrhea accompanied by a burning sensation, but these symptoms have resolved. He also used to experience frequent anxiety attacks, particularly around large crowds in the subway, which he described as severe anxiety with tightness in his chest and palpitations. During those attacks he had to “talk himself down” and said that his self-consciousness was sometimes the only thing that kept him from “breaking down”. However, since beginning treatment, he has only had one or two attacks and feels less anxious in general.
3. Current Health Status:
Appetite: frequently hungry; craves sweets and salty foods
Urine: more normal (used to be frequent, scanty and yellow)
Stool: well-formed, 1X/day *see above
Temp: tends to be warm
Sweat: no unusual sweating reported *clammy skin/limbs
Thirst: not particularly thirst; prefers cold
Energy: ok; worse when his stomach is bothering him
Sleep: no difficulty falling asleep; profuse vivid dreaming; anxiety dreams
Emotions: appears sad/resigned, easily anxious *see above; feels he’s “a wreck” right now
Head/Eyes/Ears: floaters
Other: some low back soreness and tightness in his right shoulder. Dry skin and a dry red rash over Ren 17 (no pain/itching)
4. Past Medical History: MI in December ’98; Dx: GERD, High Blood Pressure (watching)
5. Medications: antacids, garlic tablets, Prilosec
6. Allergic History: none noted
7. Physical Exam:
a. Tongue:
body: pale red with a red tip and a deep crack to the tip; puffy, scalloped; there is a faint ulcer on the right side around the lung area.
coat: thin slightly yellowish
b. Facial complexion: pale, sallow
c. Body shape and posture: withered; sunken chest
d. Shen: dull
e. Listening and Smelling: nothing noted
f. Palpation: very sunken at Ren 14, tender @ Ren 17, over the epigastric area, SP4
i. Pulse: 80bpm, weak
Right: thready, wiry
Left: soft (especially in the guan)
INITIAL DX: Stomach Heat with an underlying Heart and Spleen Deficiency
Stomach Heat Heart (blood) deficiency Spleen (Qi) Deficiency
Foul breath
Bitter taste
Acid regurgitation
Belching
Burning sensation (epigastrum)
Red tongue
Rapid pulse
Constipation w/burning Vivid dreams
Anxiety attacks
Sad appearance
Pale Complexion
Floaters
Thready pulse Abdominal pain/distension
Gas & Bloating
Slow digestion
Loose stools/diarrhea
Scalloped, puffy tongue
sallow complexion
deficient pulse
This patient’s symptoms began in the midst of his divorce 15 years ago. Constrained emotions from traumatic events can easily cause disruption of the Qi dynamic and blood flow in the middle jiao. When emotions are constrained, the Liver cannot move Qi smoothly and the Heart cannot propel blood properly creating an excess condition. Excess in the Liver can cause it to overact on the Spleen and Stomach by pathologically overloading the normal flow in the control cycle.. Over time, this has impeded movement in the Middle Jiao, eventually generating heat. The spleen, which is also taxed by excessive thinking and melancholy, was no longer able to properly process food and liquid, causing gas and bloating with loose stools. The digestive system became sluggish and the Stomach was forced to work harder to process the excess in the middle jiao. Obstruction of the Spleen and Stomach from stagnation led to a pathological intermingling of clear and turbid, which inhibited the normal physiological function and generated heat and dampness, creating alternating constipation and diarrhea. Excess in the Stomach caused Stomach Qi to rebel upward, causing foul breath, belching, acid regurgitation and a burning sensation in his epigastrum, particular at Ren 12, the Front Mu of the Stomach. Some of this dampness and heat has poured down and become lodged in the patient’s Lower Burner causing irregular bowel movement with a burning sensation.
This condition was exacerbated by the patient’s “heartbreak”. Emotional sadness has taxed the patient’s Heart Qi. Since the Heart, as the Fire organ, is the Mother of the Spleen, the Earth organ, it failed to properly nourish the Spleen. The Spleen failed to generate blood and was unable to generate Heart blood in turn. Without sufficient blood to house the shen, the patient experienced many vivid dreams and often suffered from acute anxiety as his shen was not rooted. There was not sufficient blood to nourish his face and eyes and the patient has floaters and pale complexion.
The patient’s rapid pulse reflects the heat constrained in his body. It is a thready and forceless pulse because the patient over time is developing a blood deficiency and heat has also burned up yin fluids causing the vessels to become thin and deficient. His red tongue also demonstrates that there is heat in his body and the deep central crack indicates that the heat is damaging fluids. The tongue body is scalloped and puffy due to Spleen qi deficiency failing to properly transport and transform fluids.
Initially, I made efforts to clear the heat and nourish the Heart and Spleen. The heat signs resolved first (urination became less yellow, pulse slowed and tongue became less red) and then signs of rebellious stomach qi became much milder. The patient no longer complains of bad breath and has far fewer episodes of acid regurgitation. He now has well-formed bowel movements 1X/day. His anxiety attacks have virtually stopped.
CURRENT DX: Yin Wei Disharmony
Upon palpation, this patient is tender at Ren 17, Spleen 21 and Spleen 4, as well as his entire subcostal and epigastric area. This is strongly associated with a Yin-Wei Chong Mai Extraordinary Vessel pattern. Looking over his signs and symptoms, I noticed that the rest of his presentation also indicated imbalances associated with Yin Wei disharmony.
The Yin Wei Channel dominates the interior, particularly the Qi and Yin of the Heart, Lung, Spleen and Stomach. Disorders and symptoms of those orders, such as chest, epigastric and abdominal pain, cardiac problems, fullness and distension, borborygmus, diarrhea and lumbar pain can all be treated with Yin Wei points.
This channel is also responsible for balancing the emotions. When the yin channel is disturbed, there may be mental instability, uneasiness, low self esteem, lack of will power and discouragement. Yin Wei points can be used to lift the spirit and balance the emotions.
TP: Clear Heat and Regulate the Stomach; Tonify Heart blood and Spleen Qi
Harmonize the Yin Wei channel
Acupuncture Points:
Ren 12 Front Mu of the Stomach – Influential point of Fu organs; Harmonizes Stomach & Downbears counterflow; Fortifies Spleen & Disinhibits Damp
ST 25 Front Mu of the LI – Courses & Regulates the Large Intestine; Supports Earth and Transforms Damp
LJ empowering stability during transitions.
ST 44 Ying Spring/Water – Promotes Free Downbearing of Stomach Qi; Harmonize Intestines and Transform Stagnation
Ren 17 Front Mu of the Pericardium/Influential Point of Qi – Regulates Qi and Downbears Counterflow; Loosens the Chest and Disinhibits Diaphragm
LJ reunion point where PC and Lu meet; grounds the essential child-like nature of the heart
PC 6 (L) Luo/Confluent of Yin Wei – Clears Heat & Eliminates Vexation; Loosens Chest & Rectifies Qi; Downbears Counterflow & Stops Vomiting; Harmonizes ST & Relieves Pain; Regulates HT Qi & Blood; Calms Mind; Regulates JueYin:.
LJ Regulates inner and outer aspects of illumination governed by the heart & fires of ming men.
SP 4 (R) Luo/Confluent of Chong – Supports the Spleen & Stomach and Rectifies Qi
LU 7 (R) Confluent of the Ren/Command of Head & Neck/ Luo to LI –
GM Has a releasing effect on emotions (esp. sadness, worry, grief) constraining Po in the chest.
Ki 6 (L) Confluent of Yin Qiao – Frees channels; Drains Fire & Courses Qi; Clears Spirit Disposition
Ear Seeds: Shen Men, Stomach
The point prescription was designed to clear heat, regulate and open the Middle Jiao, tonify the Spleen and calm the spirit. Ren12 and St 25 work together as both local points and front mu points of both the Stomach and Large Intestine to promote movement and downbearing, allowing heat and stagnation to move out of the body. Ren 17 assists in promoting downbearing and can also loosen the chest. As the Front mu of the Pericardium and the influential point of Qi, it can also tonify the heart and spleen. PC6 and Sp4 are the confluent points of the Yin Wei (chest/interior) and Chong (blood) and aid in downbearing stomach qi as well as tonifying the Spleen and calming the spirit. Lu 7 is the luo to the Large Intestine and also works with Ki 6 6 to open the Ren channel, where this patient reports having a burning sensation. St 44 is particularly good point for clearing heat and downbearing stomach qi and has a function to harmonize the intestines.
Other Prescriptions: SP4, PC6, Ki 9 (xi cleft of Yin Wei), Du20 Ear: Shen Men, Sympathetic
Lv 3, PC 6, Ht7, Ren 17, Sp 6, St 36
Initial Herbs:
Sheng Di Huang Clear Heat & Cool Blood; Nourish Yin; Cools Upward Blazing of Heart Fire
Dan Shen Invigorates Blood; Clears Heat & Soothes Irritability
Dang Gui Tonify/Invigorate Blood; Moistens Intestines; w/Dan shen tonifies blood & nourishes Ht w/o stagnation
Fu Ling Strengthens Spleen, Drains Damp, Transforms Phlegm, Quiets Heart & Calms Spirit
Mai Men Dong Tonifies Heart & Stomach Yin, Clears Heat, Soothes Irritability; Moistens Intestines
Wu Wei Zi Quiets Spirit and Protects Heart Qi; Binds Ki Essence; Stops Diarrhea
Suan Zao Ren Nourishes Heart Yin and Liver Blood, Quiets Spirit
Bai Zhu Tonifies Spleen Qi; Dries Damp; Stabilizes Exterior
Mu Xiang Moves Qi, Relieves Pain, Strengthens Spleen, Regulates Stagnant Qi In Intestines
Xiang Fu Moves Liver Qi
Hai Piao Xiao Binds Essence, Resolves Damp, Stops Diarrhea; Stops Bleeding; *Rebalances Stomach Acid
Huang Lian Clears heat & Dries Damp; Clears Heart & Stomach Fire; Stops bleeding (Guides to Heart)
Mu Li Settles/calms the spirit; absorbs acidity, alleviates pain, binds essence, benefits yin and anchors yang
A variation on Tian Wan Bu Xing Dan, which tonifies yin and blood of the heart and kidneys, and Gui Pi Tang, which nourishes Spleen Qi and Heart Blood. Huang Lian and Hai Piao Xiao was added to clear some of this patient’s excess stomach heat and help control stomach acids that contribute to nausea and acid regurgitation. Mu Li controls stomach acid and settles the spirit.
Current Formula:
Dang Shen 9 Bai Ji Li 9
Bai Zhu 12 Shi Chang Pu 6
Fu Ling 12 Fo Shou 12
Suan Zao Ren 6 Zhi Ke 9
Huang Qi 9 Ye Jiao Teng 9
10. TCM Patterns of “Upset Stomach”
• Spleen-Stomach Disharmony – characterized by glomus, continuous pain in the stomach duct exacerbated by hunger, abdominal distension and poor transformation of food, belching, hiccup, and in severe cases, vomitting. Other signs are a pale, scalloped tongue and thin, white fur, and a forceless, sunken, fine or sunken/moderate pulse.
• Spleen-Stomach Yang Vacuity – characterized by reduced food intake, vomiting, diarrhea, cold limbs, fatigue, withered-yellow facial complexion, dizziness, pale tongue, soft enlarged tongue, thick turbid tongue fur and a large, vacuous pulse.
• Spleen-Stomach Damp Heat – characterized by glomus and oppression in the stomach duct, torpid intake, nausea, sloppy stool, yellow urine and heavy, cumbersome limbs. The tongue is red with yellow, slimy fur and the pulse is soggy.
• Spleen Qi Vacuity – a condition arising when irregular eating or anxiety, thought and taxation fatigue damage the spleen and stomach.
• Spleen-Kidney Yang Vacuity – characterized by enduring diarrhea, early morning diarrhea, or clear-food diarrhea, drum distension and lower abdominal cold pain. Other chief signs are a bright, white puffy face and swollen limbs, a pale, enlarged tongue with white, glossy fur and a sunken, fine, slow and weak pulse.
• Spleen Vacuity with Food Damage – characterized with bloating after eating and by sloppy stool containing untransformed food. In general there is no abdominal pain and the tongue fur may be completely normal.
• Splenic Movement and Transformation Failure – In mild cases, abdominal distension, torpid intake, rumbling intestines, diarrhea and other signs of poor digestion are observed.
• Stomach Qi Ascending Counterflow – characterized by nausea, vomiting, belching or hiccough.
• Stomach Reflux – characterized by distension and fullness after eating, vomiting in the evening food ingested in the morning or vomiting in the morning food that was ingested the previous evening.
• Stomach Vacuity Cold – characterized by stomach pain, vomiting and vacuity cold signs
• Stomach Repletion Cold – characterized by acute cold pain in the stomach duct relieved by vomiting, physical cold and cold limbs.
• Stomach Heat – characterized by bitter taste in the mouth, dry mouth, bad breath, rapid hungering, red tongue with yellow fur and a rapid, slippery pulse.
• Liver-Gallbladder Damp Heat – chief signs include alternating fever and chills, bitter taste in the mouth, ribside pain, jaundice, abdominal pain/distension, nausea, vomiting and loss of appetite. Stools tend to be dry if heat is pronounce and sloppy if dampness is more pronounced. The tongue fur is yellow and slimy and the pulse is rapid and stringlike.
• Liver Qi Invading the Spleen – characterized by headache, irritability, bitter taste in the mouth, chest oppression, glomus and fullness after eating, sloppy diarrhea and a moderate, stringlike pulse. It differs from Invasion of the Stomach by a predominance of spleen signs such as diarrhea and distension.
• Liver Qi Invading the Stomach – characterized by stomach duct pain, vomiting of sour fluids, torpid intake, abdominal distension, diarrhea. There will also be liver signs such as dizziness, ribside pain, irritability and a stringlike pulse.
• Liver-Stomach Disharmony – characterized by distending ribside pain, belching, glomus, fullness, torpid intake, acid regurgitation and clamoring stomach.
• Large Intestinal Vacuity Cold – usually associated with Spleen-Kidney Yang vacuity, and is characterized by thin diarrhea, reduced food intake, cold limbs, aching lumbus, thin tongue fur and a fine, sunken pulse.
• Large Intestinal DampHeat – a disease pattern generally characterized by abdominal pain and diarrhea with ungratifying defecation and foul-smelling stool.
• Food Accumulation – pathology attributable to spleen-stomach movement and transformation failure. It is characterized by fullness and oppression, in the chest and stomach duct, in some cases with hardness or glomus, abdominal pain that dislikes pressure, hard stool, loss of appetite, foul belching and acid regurgitation.
• Food Damage – pathology due to voracious overeating or spleen-stomach vacuity. It is characterized by aversion to food, nausea and vomiting, belching, foul-smelling vomit, acid regurgitation, painful bloating, diarrhea or constipation, foul-smelling stool and flatus. The tongue fur is usually slimy or thick or yellow.
• Damp Obstructing the Middle Burner – characterized by abdominal distension, loss of appetite, sticky mouth, thirst with desire for warm drinks, short voidings of reddish urine and slimy white tongue fur.