Phlebitis

Chief Complaint: calf pain and swelling

Western diagnosis: phlebitis

Medical History:
1.Recurrent phlebitis on left calf-had same exact symptom seven years ago. He took Chinese herbal medicine and the symtoms were completely gone. It took 6 weeks to cure it.
2. smoker
3. lost his right leg on auto accident
4. doesn't drink alcohol but drinks a lot of water
5. He delivers auto parts-driving 8 hours per day. He used to work at a post office where he had to stand for 8 hours per day, again
6. His blood pressure and pulse rate is normal.

Questioning exam:
1. pain at left calf, hot sensation. Unable to relieve pain with anything. Pain at the sole of left foot.
2.Sweats a lot on warm day
3.thirst for cold water. only drinks cold water

Pulse exam: Pulse:
Left: wiry,slippery, strong
Right: wiry

Pulse rate: normal

Tongue exam: Red body
Yellow greasy coating
Distended Jinjinyuye

Left leg is swollen, hot and red

OM Diagnosis: Pain syndrome caused by dampheat.

Patient has greasy, yellow coating with red tongue which indicates dampheat
Patient drinks cold water only-heat
Patient feels burning pain on his calf and toes

Treatment Principle: drain damp
clear heat
move blood to relieve pain

Point Prescription: Patient refused acupuncture treatment. However, points that I would have used are SP9, GB34, LI4, LI11, Ba feng, ST 36. Liver2 and Liver3-all sedating method

Herbal Formula: I used concentrated granules 5:1
Si Miao San+ Huo Xue Zhi Tong Tang
Modification
add:Dilong 3g, Yinchen 2g, Xiangfu 2g, Yujin 2g, Chaihu 2g

7days, 3x/day, 4g each

Lifestyle prescription: auricular points for Shenmen, toes, knees bilaterally

Results: Patient was fully recovered after one week. Pain was completely gone, slight redness around the ankle. Patient was able to walk without cane.