Patient Last Name: WA99 Patient First Name: J
Treatment Date and Time: September 23, 1999
Sex and Age: Female, 21
1. Chief Complaint: Back Pain from MVA since May 1999
2. Medical History:
a. Present Illness: Patient complains of back pain with initial onset 1997 from MVA. She was treated successfully with acupuncture and herbal medicine over a 1 ½ year period. Three months later (May 1999), she suffered another trauma to her back in a MVA. Patient experiences pain on palpation from GB 21 down the first line of the UB channel to her sacrum bilaterally. She also experiences headache pain from GB 21 up to GB 13, 14, 15. Her pain is aggravated with forward, backward and lateral flexion and extension, damp weather, prolonged standing or sitting. Her pain is chronic, mostly dull but can be sharp and localized. Pain is alleviated with medication (Vicadan), heat, and stretching. O’Donahue’s was positive in all directions. Generally, pain without movement is 3/10, worsening at the end of the day to 7/10. She was diagnosed by M.D. as whiplashed; MRI and X-rays were negative.
b. Current Health Status:
Skin: constant itching over entire body, dry skin, especially on chest
Head: headache post MVA from GB 21 to GB 13, 14, 15
Eyes: occasional floaters
Ears: progressive loss of hearing
Respiratory: chronic smokers cough, phlegm difficult to expectorate, bronchitis history
CV: cold hands and feet, occasional dizziness
GI: nausea, better with food, history of constipation and diarrhea
Sleep: difficulty falling asleep, 5-10 hrs per night, awakes tired
Urine: frequent (every 1-2 hrs), but drinks often
Stool: 1-2x/day, occasionally loose, history of undigested food in stool
Temp: cold extremities, heat in body 98.7 degrees
App: good, eats frequently
Sweat: history of night sweats
Thirst: very thirsty, drinks often
Emotions: history of depression; suicidal tendencies after finding out she had genital warts
BP: 106/70
c. Other: Patient smokes cigarettes @ 1 pack/day; also smokes marijuana @ 1 joint every 2-3 hrs. to relieve pain and nausea
d. Past Medical History: MVA 1997, treated successfully with acupuncture and herbal medicine over 1 ½ year period. Three months later (May 1999), subsequent MVA.
3. Family Health History: N/A
4. Medications: oral contraceptives, Vicodan, Soma
5. Allergic History: N/A
6. Personal History: asthma, bronchitis, Stomach/intestinal disorders, allergies, UTI
7. OB/GYN: menarche @ 15 yrs, LMP 9/15/99, 28 day cycle, 4 day flow, dark red at onset, thick blood, clotting, PMS depression, abdominal and breast distention
8. Physical Exam:
a. Tongue: body: pink red, thin, pierced
coat: turbid white sticky in rear
veins: dark and distended
b. Facial complexion: ok
c. Body shape and posture: Patient’s shape and posture appears healthy
d. Shen: present
e. Other: movement before after
i. Neck forward flexion 6 4
ii. Neck extension 8 (↓ ROM) 6 (↑ROM)
iii. Neck L lateral flexion 5 4 (↑ROM)
iv. Neck R lateral flexion 8 5
v. Back extension unable 8 (↑ROM)
vi. Back extention (passive) 8 ——-
vii. Back L lateral flexion 7 2
viii. Back R lateral flexion 7 2
f. Listening and Smelling: no unusual odors, breathing or vocal changes were observed
g. Palpation:
i. Pulse
Level: middle
Speed: 72
Rhythm: regular
Strength: chi bilaterally was deep and vacuous, LV vacuous
Shape/Quality: tight
ii. Abdomen/Channels: Extra Channel Hara Diagnosis revealed a Ren Mai-Yin Qiao and Yang Wei-Dai Mai disharmony. Also pressure pain down UB line (relieved after treatment)
9. Differential Diagnosis:
a. TCM: Qi and Blood stagnation from trauma (underlying yin/blood ↓)
b. Japanese: Ren-Yang Wei Disharmony
A. Qi and Blood Stagnation Yin and Blood deficiency
Back pain which can be sharp itching
And localized esp. during movement dry skin
Thick menstrual blood w/ clotting floaters
depression Loss of hearing
abdominal and breast distention Cough w/ diff to expectorate phlegm
dark and distended SLV Dizziness
tight pulse Difficulty falling asleep
Deficiency heat
Night sweats
Thirst
tremors
B. Pathology: The root of patient’s pathology is a yin and blood deficiency. This deficiency can develop from years of chronic abuse of cigarettes and marijuana coupled with her history of chronic LU infections and emotional depression. The itching and dry skin result from the lack of yin and blood nourishing the skin. The floaters and progressive loss of hearing from yin and blood not rising to nourish the eyes and ears. A further progression of this lack of nourishment rising is patient’s dizziness. Due to the long-term nature of patient’s abuse of alcohol, cigarettes and marijuana despite her young age, her yin and blood have been depleted enough to result in tremors from wind arising from deficiency. Yin deficiency leads to a relative excess of yang and causes deficiency heat, night sweats and thirst, as well as difficulty falling asleep due to yin’s inability to house the yang at night.
With this yin and blood deficiency at the root, patient suffered severe trauma to her back and neck from a series of motor vehicle accidents over a short period of time. This trauma caused qi and blood stagnation manifesting as back pain which can be sharp and localized especially during movement. This stagnation interrupted the qi and blood dynamic in the body causing a menstrual period characterized by thick dark blood with clotting, PMS, depression and breast distention. It is further evidenced by her dark and distended sublingual veins. This stagnation has remained over a long period of time partly due to her yin and blood deficiency. With such a deficit of yin and blood, coursing qi and blood becomes difficult due to the danger of creating more deficiency. With a greater degree of deficiency, there is less blood to course, and deficiency can easily lead to excess, i.e., stagnation. Furthermore, the trauma has caused damage to the tissues, sinews, muscles, ligaments, etc. In order to fully heal these tissues, blood and yin fluids are needed to nourish them. The lack of blood and yin fluids makes this process difficult and further leads to the degeneration of these tissues creating a devastating cycle with an inability to resolve her disharmony.
10. Treatment Plan: Course qi and blood and relieve pain; harmonize Ren-Yang Wei
11. Prescription:
a. Acupuncture:
i. Root Step 1: SJ 5, KI 6 (retain 2 min, check abdomen; if + add
GB 41, LU 7 (hook IP cords, retain 10 min)
ii. Root Step 2: R UB 22, R UB 19, L UB23, L UB 13 (retain 5 min)
iii. Branch: thread down UB first line bliaterally
iv. Tuina on upper and lower back
v. Stretching
b. Acupuncture Analysis:
SJ 5: confluent of yang wei mai
KI 6: confluent of yin qiao mai
GB 41: confluent of dai mai
LU 7: confluent of ren mai
c. Herbs: Meridian Passage
d. Herbal Analysis:
This formula is a combination of Shen Tong Zhu Yu Tang and Mo Yao Xiang Sheng Dan. It is for congealed blood in the meridians, joints, low back and limbs. It consists of:
Hong Hua: invigorates blood
Niu Xi: invig blood, nourishes LV and KI
Qin Jiao: expels wind damp, softens tendons, guide to meridians
Qiang Huo: wind damp, focus on KI and UB
Chuan Xiong: invig blood, expels wind
Dang Gui: invig and tonifies blood
Xiang Fu: moves qi along with the blood
Gan Cao: harmonizes, focuses to meridians
Mo Yao: invig blood, promotes healing
Zi Ran Tang: invig blood, enters LV and KI
Gu Sui Bu: tonifies KI, heals bones and tendons
Bai Shao: tonifies blood, smoothes LV qi, important for pain and spasms
Ru Xiang: invig blood, relaxes muscles, stabilizes pain