Chief Complaint: muscle spasms
Medical History: Patient presents as 37 year old female. “Perfect health” until onset of current symptoms 5 months ago. Active lifestyle- feels best after exercise. Well balanced and moderate diet. Non-smoker, occasional wine, coffee daily.
Questioning exam: Onset of Symptoms: 5 months ago (symptoms started appearing shortly after giving birth). First symptom was closing of the eyelids. She was forced to hold her eyelids open with her fingers about 70% of the time. A few weeks later, her vocal cords tightened over the trachea and restricting breath. On her third trip to the ER, she was given a tracheostomy tube which she is still breathing through. Her vocal cords were then injected with botox in attempt to relax them. She then began suffering from dystonias in her neck, causing intense pain, rigidity, and a “bobble-head” appearance. She has seen 5 neurologists, who have prescribed a myriad of drugs from anti-anxiety to muscle relaxants to more botox. The drugs did not help her, but did cause unpleasant side-effects.
The week before she came to me, she had her first period since the delivery. This made her symptoms much worse.
Pulse exam: Pulse was overall thin, weak and slightly rapid. The left side was more superficial and wiry.
Upon palpation, GB 20 was incredibly tight and painful. As were ST 12, Naganos, LI 4, GB30, GB34, GB41, and LR3.
Tongue exam: Tongue body thin, extremely pale, and had lots of transverse cracks. Body was very quivery and unable to patient unable to stick it out. Not much of a coat and very dry.
Wood body and personality type- thin, sinewy, slight green tint to skin, use to being in control. Patient is very irritated and angry about current condition.
OM Diagnosis: Internal Liver wind due to Liver blood and yin xu.
Treatment Principle: Clear wind, smooth Liver, tonify blood and yin.
Point Prescription: First treatment was the Agressive Energy Treatment (Worsley). UB 13, 14, 15, 18, 20, 23
After that, I alternated tonifying treatments with clearing treatments.
Tonifying treatments included:
Opening the Chong (SP4 + P6) or Ren (LU7 + KI 6)
UB 15, 17, 18, 20
or
8 needles around naval
Clearing wind included different combinations of the following
Yang Wei Mo (SJ 5 + GB 41), GB 20, Naganos, LI 4, UB 12, GB 31, GB34
Cupping with Po Sum On on back and shoulders
Handwork on shoulders, Naganos, LI 4, and GB channel
Tiger thermie on ST 12
Herbal Formula: Women’s Precious as directed from Golden Flower
Lifestyle Prescription: Instructed to avoid chicken, caffeine, and alcohol increase cooked leafy greens
Results: Results were great and she was symptom free after 6 treatments in 2 weeks. I then instructed her that I wanted to see her weekly through 3 menstrual cycles. However, she was feeling so good and was busy, so she failed to come in for 3 weeks and stopped taking her herbs. In the third week she had a period. The period was very heavy and painful. All of her symptoms returned, we began again and results are coming slower this time. It has been 2 months since she resumed treatment and was doing well until her last period when her symptoms moved from the back of her neck to the front of her neck (from Tai Yang to Yang Ming). Treatment has been modified and we’re continuing to work on it.
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