Chief Complaint: Left Heel Pain
Medical History: At age 14, he was diagnosed with polio. And ever since then fear has been one of the predominating emotions in his life. In 1997, he voluntarily underwent a vasectomy. He felt this would allow him to engage in a fulfilling sexual lifestyle, without the worry of ever having any children.
He is a tall man, standing over 6’5, and possessing a very muscular physique. He is also currently undergoing marital strife, as I also treat his wife as well. There are seeking marriage counseling.
Questioning exam: His temperature runs very hot in general, experiencing steaming bone like heat, manifesting mainly in the left foot heel, as well as his left rib cage. He experiences night sweats to the point where the sheet is drenched in the morning. He also dreams of killing and flying. He is thirsty but has no desire to drink. He experiences palpitations and anxiety throughout the day, as well as intermittent depression.
Pulse exam: His pulse on left side is: Heart: Deep, Thready, Sl. Slippery. Liver: Sl. Choppy. Kidney yin: Deep, Almost Absent. The overall impression on the left side is one of yin xu in kidney and heart. His liver blood volume is surprisingly strong. However, the liver pulse is slightly floating. (liver yin growing weaker, with uprising liver yang…)
His Pulse on the right side: Overall has root, is present at all three positions, as well as all three levels. His Kidney right pulse is abundant. The spleen/stomach is is slightly tight & wiry. There is no floating characteristic on the right side, as there is on the left.
My interpretation of the pulse is one prenatal qi & jing insufficiency. (The left side is overall weaker than the right)…..His post natal qi capacity is quite strong, which is what has kept his head above water this long, considering he is undergoing a potential divorce, as well as physical debility.
Tongue exam: His tongue is red, scalloped edges, ulcerations on the sides (liver & gb), and has a scanty coat. He also has a deep fissure running from the lung to heart area on his tongue, which creates a separation at the tip of his tongue.
Upon observation and palpation his left ear tested positive for reactivity in the heel, foot, genital area, heart, ear apex, neurasthenia, anxious point. His ear also reveals that his constitutional blood pressure is hypotensive.
OM Diagnosis: Internal organ Dx: Kidney and Liver yin xu, with false heat Channel Pathology: Shao yin imbalance. Etiology: Fear
Point Prescription: On the first visit, I bled 10 drops of blood from his left ear apex. I put needles in Mu Guan, and Gu Guan on his right hand. I immediately asked him to stand, and he put weight on his left foot. He immediately was able to stand and bear weight on his foot with ease, and no pain. I then stimulated mu guan and gu guan in his right hand and had him walk as I did so. I repeated this every ten minutes. Intermittently, I put ear seeds in the heel and foot point in his left ear, and then did qi gong on both ears, then stimulated the ear seeds for 15 minutes.
I chose no further acupuncture points so that he could move and walk during the treatment.
After retaining the needles for 45 minutes, his pain was reduced 90%, and his range of motion in both plantar flexion and extension was improved. He was also able to walk out of the office without the cane.
After four treatments over the course of 1 month, he reports that the overall improvement is 80%.
Herbal Formula: He is taking 4 tablets, 3 times a day of Channel Flow (health concerns). He also is instructed to press on his ear seeds throughout the day. The ear seeds are removed every 5 days. And then replaced during his next visit.
In addition to Channel Flow, I have written him the following formula to address the root condition, which I believe to be Liver/Kid Yin xu with false heat.
Hu Qian Wan (Hidden Tiger) 85% Xu Duan 7.5% Gu Sui Bu 7.5%
After the heat is under control, I will ad some Lu Rong to replenish his kidney jing. However, I feel that it is simply way to warming for him now.
Results: His podiatrist is very thrilled with the results so far. The patient will continue to be treated until his the condition is 100% improved., and continue to take his herbs. Perhaps in the next few weeks channel flow will be decreased, and eventually eliminated from the herbal protocol, and only the constitutional formula will be taken and modified as needed throughout his course of treatment.
0 komentar:
Posting Komentar