New Case: Athletic overuse

[Guest guest]

Hi Everybody!

 

Slow in the summer, but finally got a new patient. I invite your comments

and suggestions on this case.

 

Regards,

 

Pete

 

Patient: male age 39

 

What is your major complaint? Residual pain, quadriceps and upper back.

How long have you had this condition? 10 years.

What treatments or remedies have you tried for this condition? Spinal

fusion operation, which helped. Also acupuncture 3 years ago.

 

 

Have you seen a Western Doctor for this condition? Yes.

Have you ever had to wear eyeglasses? Yes.

Have you ever had or do you now have blood in your bowel movement? Seldom.

Vioxx related.

Have you ever had or do you now have increased appetite? Frequent, due to

activity.

Have you ever had or do you now have increased thirst? Frequent, due to

activity.

Have you ever had or do you now have decreased appetite? Seldom.

Have you ever had or do you now have itching? Seldom. Dry skin due to pool

chlorine.

Have you ever had or do you now have back pain? Frequent.

Have you ever had or do you now have frequent urination? Frequent, related

to high liquid intake.

 

(male only section)

Have you ever had or do you now have bloody or other discharge from your

penis? Once 1989, " prostate aggravation " .

(end of male only section)

 

Have you ever had or do you now have muscle pain or cramps? Frequent.

Have you ever had or do you now have backaches? Frequent.

Have you ever had or do you now have insomnia? Seldom.

Have you ever had or do you now have nervousness? Seldom.

Have you ever had or do you now have irritability? Seldom.

Have you ever had or do you now have morning tiredness? Seldom.

Do you have or have you had balance problems recently? Yes, since back surgery.

Do you have or have you had athlete's foot recently? Yes.

Do you have or have you had cold intolerance recently? Yes, last five years.

Do you have other items of physical fitness you want to mention? Yes, Does

tri-athalon, swim, bike and run.

Is there a history of diabetes in your family? Yes.

Who had diabetes in your family? Father's mother.

Is there a history of heart trouble in your family? Yes.

Who had heart trouble in your family? Father's brothers, 2 out of 4.

Is there a history of stroke in your family? Yes.

Who had a stroke in your family? Father's mother.

 

Is there a history of high blood pressure in your family? Yes.

Who had high blood pressure in your family? Mother, father's brothers.

 

Please list all operations you may have had, and your age when you had them.

Yes, spinal fusion at age 36.

 

Observe:

 

Clear moist color (indicates intact Stomach-Qi)

The eyes have glitter and reveal inner vitality. Yes.

Healthy color around wrists and ankles. Yes.

Observe the Thenar Eminence. OK.

Tongue color. Pink.

Tongue shape. Rounded.

Tongue coating. Slight white.

Tongue moisture. Moist.

 

Inquire:

 

Gradual onset of headache. Yes. Very infrequent, every 2 months max.

Time of day when the head aches. 2 - 4 PM

Location of the headache. Frontal.

Character of the headache pain: Dull.

Condition of the patient while having the headache. OK, not severe headache.

Pain that is diminished by heat. Yes or no. Doesn't know?

Pain that is diminished by cold. Yes or no. (heat) Doesn't know?

Pain that is relieved by touch or pressure. Yes or no. (deficient) Doesn't

know?

Pain that is worsened by touch or pressure. Yes or no. (excess) Doesn't know?

Pain that is better after eating. Yes. (deficient)

Sensation of heaviness. Yes, sluggish always with pain. (damp cold, damp

heat, qi deficiency or bi syndrome)

Pain that moves from place to place. Yes or no. (wind)

Slight pain with fatigue. Yes. (deficient qi or dampness)

Clear Urine. Yes, sometimes.

Dark Yellow or Reddish Urine. Yes, sometimes.

Not able to fall asleep. Yes, sometimes.

Dream disturbed sleep. Yes, sometimes.

Wake up early and not able to fall asleep again. Yes, sometimes.

Change in sinews, such as weak or stiff. Yes.

Throws off the blanket at night. Yes. (excess heat maybe liver or heart)

 

Listen & smell:

 

 

Palpate:

 

Systolic blood pressure (Optimal <120; 119.

Diastolic blood pressure (Optimal <80; 72.

Heart rate. 55.

Sinking pulse. Yes. (yin, internal disharmony or obstruction)

Slow pulse less than 70 beats per minute. Yes. (cold or insufficient qi)

Short pulse, does not fill the spaces under the three fingers and is

usually felt in only one position. Yes. (often sign of deficient qi)

Hidden pulse is an extreme form of the sinking pulse. Yes. (If strong,

Deficient Cold obstructing the meridians)

Dry skin. Yes. (deficiency of liver blood)

Itchy skin. Yes. (wind)

 

 

Summary: Residual pain, quadriceps and upper back, for ten years. Has had

spinal fusion surgery, this has led to balance problems, but helped the

back pain. He is a competitive tri-athlete swim, bike and run. Cold

intolerance for the last 5 years. Has muscle pain and cramps. Also

athlete's foot infection.

 

Has had blood in the bowel movement, although seldom. Seemed to be Vioxx

related.

Pain is better after eating (stomach deficiency)

Sensation of heaviness (dampness or qi deficiency)

Some sleeping problems.

One heat sign, throws the covers off.

Pulse is sinking, almost hidden. (Deficient cold obstructing the meridians.)

Pulse is very slow, 55. (Cold or insufficient qi)

Short pulse (deficient qi)

Tongue is unremarkable.

Dry skin (deficiency of liver blood)

Itchy skin (wind)

 

Acupuncture impression: Cold dampness, deficiency of stomach, qi and blood

complicated by wind.

 

Treatment principle: Dry dampness, warm and tonify stomach, qi and blood,

calm the wind.

 

Possible Points: UB 20, 21; P 6; Lv 13; St 21, 36; Ren 6, 12; LI 4, 11; Lu

7; Sp 6; Ashi.

 

Herbal Pills: 4C1-* series.

 

Vioxx has been taken off of the market due to increased risk of heart

attacks, strokes and blood clots. I recommend that you never take Vioxx again.