Chief Complaint: Abdominal problems and hypertension for about 3 years, due to stress.
Medical History: The patient claims that she has been under a tremendous amount of stress in the past three years, which have lead to her development of hypertension and dysrhythmias. She has been on anti-hypertensive medications, but these tend to make her feel tired and weak. She states that her stress level is high which prevents her from having a good night sleep.
She complains that she has gained weight, her facial muscle tone has decreased and has generally not felt “like herself” in almost a year now. She asserts that her appetite has increased, she is always cold and her energy level is vastly decreased. She has never sought the attention of an acupuncturist, and is open to new ideas and treatments at this point.
Questioning exam:
Medical History:
Irregular heart beat for about 3 years.
Hypertension for 3 years.
Herniated disc around L4 secondary to trauma for about 5 years.
Allergies:
No known drug allergies.
Current Medications:
Atenelol 5mg/day.
Hyzaar 100mg/day.
Multivitamins 1/day.
Emotional Status:
She claims that she is usually good at channeling negative energy, however she states that given her state of health for the past 3 years have really left her feeling rather down.
Habits:
Smoking-1 pack per day.
Alcohol-Occasional.
Coffee-Rarely.
Cravings-Denies any specific cravings.
Inquiring:
Appetite and Diet:
She claims her appetite is in excess especially in the last 3-4months. She has tried to eat healthy most of her life, but states that recently she has been more prone to snacking on junk food. She usually eats 4-5 small meals a day. She has no food allergies.
Thirst:
She drinks about 2-3 bottles (16oz) a day. She rarely drinks coffee or sodas.
Bowel Movements:
She has a bowel movement once a week, it is usually very constipated, hard and tough to pass. This is one of her complaints. She denies any bloating, gas or reflux.
Urination:
She has no difficulty urinating. Her output is about equal to her intake, and she denies nocturia.
Sleep:
She claims that she has no trouble falling sleep, but she wakes up at about 2-3am and has a hard time falling back to sleep. She gets about 6 hours of sleep/night, but has a very difficult time getting out of bed and feels tired through out the day. She occasionally drinks herbal tea to help with her sleep, but this is another area which she would like to improve by acupuncture.
Body Temperature:
More sensitive to cold recently, she feels sudden “chills” on occasion.
Perspiration:
No abnormal sweating, denies night sweats.
HEENT:
*Head-History of migraines in the past that have now resolved.
*Eyes- Declining vision.
*Ears-Declining hearing.
*Nose- Normal.
*Throat- Normal.
Pain:
Occasional leg cramps.
Menstruation/Leukorrhea:
Menarche was at the age of 14. She has had regular 28 day cycles until about a year and a half ago. At that time she began long periods of continuous bleeding that would stop for about 6 weeks and then resume. She has been on hormone therapy but claims that the bleeding is still prevalent. She states that the color is dark and light, with no clots. She denies menstrual cramps.
She had 4 pregnancies, 2 miscarriages and 2 live births.
She denies the presence of leukorrhea at this time.
Pulse exam:
Slow in general, rate of 52bpm.
Left:
Thready and hesitant, kidney is impalpable.
Right:
Thready and rolling, kidney is impalpable.
Tongue exam::
Proper (Body):
Large tongue, swollen with teeth marks. Pale reddish-purple in color.
Coating:
Thick white coating.
OM Diagnosis:
Liver qi stagnation.
She appears to be under tremendous stress, and in general seems angry, and very short in her responses. She experiences migraines, and does have high blood pressure related to her stress.
Spleen qi deficiency.
A significant difference in her appetite and energy level. She also experiences constipation.
Heart yin and blood deficiency.
She experiences arrhythmias, and night sweats.
Treatment Principle: Principal of Treatment:
Sooth liver qi.
Tonify spleen qi.
Nourish heart yin and blood.
Point Prescription:
LI4, Liv3, Liv13, Sp6, St25, Ren12, St37, PC6, K3, Ht7, GB14, Yintang.
Lifestyle Prescription: It was recommended that she try some exercise and/or relaxation techniques
to help alleviate some of the stress in her life.
Smoking cessation was also highly encouraged.
Results: The patient had 9 treatments weekly. Her constipation had resolved significantly, and her migraines had dissipated.
After consulting with her physician, with acupuncture as an adjunct she was able to reduce her hypertensive medication, leading to more energy and less stress. This was an extraordinary case of success, an an example of how TCM can be used as an adjunct therapy to improve quality of life and reduce requirements for medications that have side effects. Most of her Symptoms: constipation, lack of energy, feeling tired and headaches were side effects of the high dose of anti-hypertensive medication she was on, and by reducing her requirements her symptoms slowly dissipated. We checked her BP every week and worked on establishing a regimen her and her physician were comfortable with.
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