Chief Complaint: body aches all over
Western diagnosis: fibromyalgia
Medical History: the patient is an electrition who loves spicy food, exercises not at all. Being an electrition in Maine working in very hot and humid environments in the summer and very cold and windy environments in the winter
Questioning exam: Pain migraites, is better when cold, the pain is dull achey in nature
Pulse exam: pulse is slippery, slightly wiry, large joints appear swollen and red and are hot to the touch
Tongue exam: red with a thick white coat
OM Diagnosis: wind cold bi rational is that the pain migrates is better in the cold
Treatment Principle: disperse wind and warm the cold
Point Prescription: LI 4, LV3, GB20, UB10, SJ5, LI11, ST40
Herbal Formula: Herbs are from Standard Process: Hepatrophin 2 tid, Spleen PMG 2 tid, Okra Pepsin 2 tid, Min- Chex 3 before bed, Magnesium Lactate 3 bid
Lifestyle prescription: no spicy food, beer or alcohol, ice cream
Results: after six months of treatment (mostly herbal) the patient after consulting primary physician has stopped taking his Vioxx and is able to work almost a complete work day pain free
Synopsis: regular acupuncture + compliant herbal patient + time = results
Rabu, 28 Januari 2009
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