Chief Complaint: Constipation after childbirth 31 years ago!
Western Diagnosis: Constipation
Medical History: 58 yo female,born in Switzerland; came to America with husband (business assignment)5 years ago. Upper/lower GI endoscopy revealed negative. Hysterectomy 6/01 due to uterus prolapse. Organic food, vitamins, and perform yoga exercise daily.
Questioning exam: BM once a day in the morning; however had to wait for at least 45 minutes before defecation and required great effort to empty the bowels with complete relief. Stool is formed,in the soft side, brown color with no abnormal odor. She also complains of spontaneous sweating, and low energy (fatigue); a sensation of fullness in the stomach and lower abdomen.
Pulse exam: Pulse is thin,submerged; 66 bpm. Abdomen is soft to palpate, and warm in temperature. Incision is somewhat sensitive to touch. Bowel sign is present.
Tongue exam: The tongue is light red with a thin white coating, slight puffy with scallop both sides; no sublingual vein present
OM Diagnosis: Qi Deficiency-type constipation. The constipation was due to deficient Qi after childbirth. When Qi is deficient, the Large Intestine becomes weak in transporting it’s contents, thus causes the delay to defecate. The spontaneous sweating and fatigue also indicate deficiency of Qi. The weak, slow, submerged pulse is also manifestations of Qi deficiency
Treatment Principle: Tonify the Qi and release the bowels
Point Prescription: SJ 6
LI 4, 11
St 25, 36, 37
All points are needled bilaterally
Herbal Formula: Bu Zhong Yi Qi Tang plus Tao ren in granules 2g(about 2 leveled teaspoons) twice a day
Lifestyle Prescription: Add Huang Qi(3-4 slices) to make soup base
Results: After three treatments, the patient waited 20-30 minutes to empty her bowels and less effort was needed than before. Pt now is out of town for one week and I’ll see pt after her trip
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