Medical History: He does not have any immunizations at 30 months. Chronic chest infections, and sinus infections. Diet is rather good, no dairy products. He drinks soy milk and eats organic foods only. He does consume a quite a bit of high sugar fruit juice. For a 2 1/2 year old child, he gets plenty of exercise daily. Generally has a good appetite, no apparent allergies, has a strong thirst, mucus and cough occasionally, generally has loose stools. He also has a full body rash which is red patches for 2 days.
Questioning exam: Sleep, his sleep is usually restless.
Has a high fever at 104 degrees.
Has not appetite, profuse sweating, He has not had a bowel movement for three days, he had not urinated in two days and if he did it was very scanty strong odor, inability to focus and sit up, severe dizziness, very lethargic, too weak to stand up ” ( These questions and answers were given by his mother). When his mother and the infant ( David) arrived at the clinic he was so weak that she had to carry him in. Severely dehydrated.
Pulse exam: His pulses were full rapid surging.
His index finger sign was bluish purple extending into and through the Qi gate and extending slightly into the life gate. On palpation, his whole body was hot to the touch.
Tongue exam: His tongue was crimson. Observation of severe lethargy, extreme weakness, could not keep his eyes open. He has a severe cough with scanty yellow sputum, Tongue has a yellow coating
OM Diagnosis: Full heat in the Qi level, with phlegm heat obstructing the lungs and heat invading the pericardium causing shen disturbances. He has cough with rattling sound in the chest, severe dizziness which indicates phlegm, full heat in the Qi level with full rapid and surging pulse, lethargy, severe restlessness and high fever with constipation, scanty yellow urine with strong odor
Treatment Principle: Clear heat out of Qi level, Clear toxins, resolve phlegm, open up the heart orifice, ascend clear Yang Qi
Point Prescription: needled Du 13 and Du 14 did not retain needles, Cupped Du 14 to draw blood, needled UB 13, 43 needled in and out, did guasha along the Bladder channel
Herbal Formula: Herbal tea infusion, Gan Mao Tui Ren Chong Ji. (adult dose 4 tea packets 4xdaily) For 2 1/2 year old 1 packet 4x a day. take for 4 days.
Results: Results, great immediately responded, he quickly became aware, his eyes had a healthy shen sparkle, he quickly got his appetite back, his pulses were slightly rapid, the heat in the body was diminished,the body rash was 90 % gone by the end of the treatment. He had lots of energy and was able to walk. He actually ran happily out the door. The results of the treatment was unreal.
Synopsis: FOLLOW UP: The next day I saw them. The rash was 95% gone. His mother said ” he slept the best night in a long time. That same night of the treatment he went out and played with his neighbor. He still had a slight fever pulses were slightly rapid, of coarse, a child’s pulse at that age is usually rapid, so that is a healthy normal pulse. The herb tea is helping greatly. The same evening of treatment, patient had 2 full bowel movements. Urination returned to normal.
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