Chief Complaint: Pain and numbness post-surgery.
Western diagnosis: Bengin brain tumor located superior to l. mastoid process.
Medical History: Patient is a 35-year old female with main complaints
of: reovering from l. mastoid/bengin brain tumor, right lower quadrant
abdominal and l. eye surgery (wt. put in l. eye m. so upper/lower lids
would be functional). Secondary complaints include emotional trauma
related to family situation/ pending divorce.
Questioning exam: Questions mainly revolved around post-surgical sx/s.
Including: loss of sleep, numbness l. side of face and behind l. mastoid
process/ear at incision site. Left side of face muscles do not function:
patient can smile and use mouth on the right side but not left side.
Pulse exam: Pulse: slippery and full in Spleen position. Otherwise
Liver is wiry and excess, while Lung and Kidney are both Qi-deficient
Tongue exam: Tongue exam: tongue has thick, light yellow in color
coating over the Sp/St region, with teethmarks on the side indicative of
Spleen qi deficiency/dampness. Addtional: red dots on tip of tongue.
OM Diagnosis: Surgical sites/dermatomes of facial region: stagnation
of qi and blood along Classical TCM meridians of St, Gb, Li; and along
EAV meridians: Lung, Li, Fibroid degeneration organs of abdomen and
minor pelvis and Fibroid paranchymal/epthelial degeneration meridians
and the affected dermatomes for those regions. Secondary diagnosis by
TCM would be Spleen qi deficiency with acquired damp.
Treatment Principle: (1) eliminate Spleen damp, (2) tonify Spleen qi,
(3) move qi and blood in the meridians and the affected dermatomes (see
Point Prescription: VGB2,3, GB19, ST6,7, LI21, Taiyang, Bl13,43,12,42,44,14,23,GB20-22 (L) LMV2,3 (for lymphatic drainage of the
face, there is left-sided facial edema); Kid6, Lu7, TB5, GB41,34 ®
Liv3, Li4,Lu7, Li10; Hua Tuo Jia Ji C2-T2 with microcurrent therapy
setting at 150 ua, (-) polarity all around the dermatomes and meridians
and acupuncture points on the (L) side of face, as well as posterior (L)
mastoid surgical site. All points were done bilaterally except where noted.
Herbal Formula: Patent Rx: Liu Jun Zi; 5 pills t.i.d. with meals.
Aloe vera juice: 8-10 oz. in divided doses, for lympathic drainage.
Anti-oxidants: vit E @ 800-1200 I.U. in divided doses per day, Vit C
2,000-3,000 mg/day in divided doses to bowel tolerance level (help
regenerate tissue, speed healing).
Lifestyle prescription: Microcurrent as noted above. Application of
cold pressed castor oil to ® lower quadrant incision site to help
soften scar tissue and enhance lymphatic drainage.
Results: Post-treatment results after the first treatment were good.
Patient was encouraged as she was able to use (L) sided facial muscles
post-treatment when she smiled and she reported having more normal
sensation in the affected areas.
Synopsis: Referred this patient to counseling for Domestic Violence as she and her 4 children are in a potentially life-threatening environment.