Chief Complaint: Muscular pain/ achiness
Western Diagnosis: Fibromyalgia
Medical History: Patient: female, 42 years old
Since February 2000, patient had experienced muscular pain. In April 2000 she was diagnosed with Lyme’s dx and put on antibiotics. After no relief, a spinal tap and Tender Point Assessment test were performed. She was diagnosed with fibromyalgia in the summer of 2000. Significant medical history includes saline breast implants in 1983, gall bladder was removed in 1984 and in 1993 the patient was diagnosed with severe allergies and asthma. Medication at the time of visit included Arthrotec and Maxalt.
Questioning exam: The patient complained of constant, full body, muscular discomfort. Her body was achy and she felt a heaviness in her muscles. The most uncomfortable areas included her thighs, her feet, her neck and her arms. The discomfort was worse in the evenings when lying down and in morning upon waking up. At these times she felt stiff and tight and said she felt “like there were no fluids” in her body. In addition, the cold, damp weather made her symptoms worse. Other symptoms associated with her c.c. included extreme sensitivity upon palpation or pressure to the superficial layers of skin, poor circulation and a constant feeling of coldness. She was sensitive to pressure including fabrics on her skin. In addition she experienced one-sided headaches along the GB channel that occurred randomly and lasted from days to weeks at a time. Her vision had declined in the last four years and she experienced occasional blurry vision and spotted vision. Her mouth was usually dry, she had a very poor memory and often felt like she was “in a fog.” She had SOB upon exertion, her energy was extremely low (3% of 100%), her sleep was disturbed, waking frequently at night and waking in the AM feeling tired, and her digestion was affected by cold,damp foods which would cause bloating, gas and nausea. She maintained a 30-day menstrual cycle with approximately 5 days of bleeding. Premenstrually, she would experience breast tightness on the sides (liver/ GB channel), her muscular pain got worse and she became emotionally sensitive
Pulse exam: Upon palpation, the lower spleen channel was tender especially at Sp 6 and 9. Her hands and feet were cold to touch. The pulse was 80 BPM, the left weaker then the right. The left was wiry and the chi position was deep and weak. The right side was slippery and the chi was also deep and weak.
Tongue exam: The patient appeared tired and weepy, her eyes were glassy and her palms, soles and complexion had a yellow hue to them. The tongue was pale-purple in color with a scalloped body. There was a thin white coat and the SLV were distended.
OM Diagnosis: The patient was diagnosed with Spleen Qi Deficiency with Damp Accumulation. The quality, the location, and the timing of the pain as well as the precipitative and palliative factors all point to this diagnosis. The quality of pain was expressed as achey and heavy. This could be interpreted as a damp accumulation or a bi-syndrome, in particular, a cold-damp-bi. However, since it was a full body muscular pain and not specific to the joints, I leaned more towards the damp accumulation. In addition, there was no actual swelling and although aggravated by the cold, damp weather, her symptoms were the worst in the summer. The fact that she felt “like there were no fluids” in her body, can emphasize this improper transport of fluids due to damp accumulation. The major characteristic of dampness is heaviness, which was her major complaint. Since this was a stagnant disorder, the pain was the worst at night and in the morning, when the patient was sedentary. The dampness could be seen in her tongue and felt in her pulse. Since dampness can injure the yang, her constant feeling of coldness and poor circulation could be due to the dampness hindering the ability of the yang/ qi to transport and warm. The spleen qi deficiency symptoms included her lack of energy, her inability to concentrate and her digestive problems associated with particular foods.
Treatment Principle: The treatment plan included tonifying the spleen qi and dispelling the damp accumulation. In addition warming was necessary to circulate the qi and warm the yang.
Point Prescription: Acupuncture was difficult at first since the patient was very sensitive to the needles. It included Sp 6, LI 4, Liv 3, St 36, Pt 0 in the ear and ear shen men. Each treatment consisted of lots of moxabustion, especially on points Sp 6, St 36 and Ren 4 and 6.
Herbal Formula: An herbal formula was not used due to her food allergies, which included most herbs.
Lifestyle Prescription: It was mentioned to the patient that dietary factors play a major role in spleen qi deficiency and damp accumulation. It was advised that she eat more warming and cooked foods. A congee recipe was offered. In addition, I suggested that daily, light exercise and/or stretching would be helpful in her stagnant situation.
Results: During the initial visit, she was very sensitive to the needle insertion and it took 5- 10 minutes for her to feel the heat from the moxabustion, if at all. After the first visit, she felt much warmer and by the fourth visit the body aches were less severe and in more concentrated areas. By the second month, the aches and heaviness was much better, the patient was able to concentrate and go back to work, her energy was better and she was not as cold, to the point where she could wear lingerie to bed for the first time in a year.
Synopsis: My major concern for this patient was the fact that her health began to decline after her breast implants. I had a feeling that this was the cause of her problems and that she should really make sure there was no problems associated with them. I had asked her to have them checked for many weeks and it wasn’t until the second month that she tried to contact the doctor who had done the procedure. Sure enough, the doctor was no longer working and my patient was told that many women with this procedure had complications. She immediately went to get them removed and it was found that one of the implants had leaked and caused this systemic reaction.
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