New Case: Obesity

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Hi Everybody!

 

Female: Age 37 Record Jan 11, 05

 

Summary:

 

Acupuncture impression: Damp Phlegm with Qi deficiency, complicated by

Blood, Yin and Yang deficiency as well as internal disharmony. Liver, Lung,

Kidney, Gall Bladder, Spleen and Stomach are involved. There are

additionally cold, heat and dryness signs as well.

 

Treatment principle: Expel Damp Phlegm, tonify Qi, Blood, Yin and Yang.

Harmonize the interior. Regulate food intake and encourage mild exercise.

Tonify Liver, Lung, Kidney, Gall Bladder, Spleen and Stomach.

 

Possible starting Points: LI 4, 11; Lu 7; Sp 6; St 36; Ashi. Ear Weight

Protocol.

 

Herbal Pills: The following may be of use initially: 7 C 1 - 8 Wen Dan Tang

Wan " Rising Courage Teapills " ; 11 E - 1 Bojenmi " Weight Loss Tea " .

 

What is your major complaint? Overweight

How long have you had this condition? Since 2001

What treatments or remedies have you tried for this condition? Atkins,

Nutri-System

 

Medical History:

 

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

Have you seen a Chiropractor for this condition? No, but for an auto accident.

Have you ever had chronic or frequent colds? Yes.

Have you ever had stomach, liver or intestinal trouble? Yes, Stomach.

Have you ever had a reaction to serum, drug or medicine? Yes.

Have you ever had a tumor, growth, cyst or cancer? Yes, cyst on ovaries,

shrunk with drugs.

Have you ever had to wear eyeglasses? Yes.

Have you ever had ear, nose or throat trouble? Yes, tonsils.

 

(female only section)

Have you ever had a pregnancy? Yes.

Have you ever had a vaginal discharge? Yes.

Have you ever had treatment for female disorder? Yes.

Have you ever had painful menstruation? Yes.

Have you ever had irregular menstruation? Yes.

How old were you when you had your first menstrual period? 13.

What is the interval between your menstrual periods? 28 days, on Birth

Control pills.

How long do your menstrual periods last? 6 days.

When was your last period? 2 weeks ago.

What is the quantity of your menstrual discharge? Normal.

Have you ever had or do you now have bloody or other discharge, non menses?

Seldom, once.

 

(end of female only section)

 

Have you ever had or do you now have shortness of breath? Frequent.

Have you ever had or do you now have swollen ankles? Frequent.

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

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

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

Have you ever had or do you now have sore throats? Frequent.

Have you ever had or do you now have nosebleeds? Seldom, when out west.

Have you ever had or do you now have asthmatic wheezing? Seldom.

Have you ever had or do you now have pneumonia? Seldom, 4 or 5 times as a

child.

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

Have you ever had or do you now have abdominal pain or cramps? Seldom.

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

do you now have increased appetite? Seldom.

Have you ever had or do you now have increased thirst? Seldom.

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

Have you ever had or do you now have nausea and vomiting? Frequent, ice tea

with sugar causes.

Have you ever had or do you now have back pain? Frequent, caused by having

to sleep on a pillow.

 

Have you ever had or do you now have arthritis? No.

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

Have you ever had or do you now have painful joints? Seldom.

Have you ever had or do you now have backaches? Frequent, caused by having

to sleep on a pillow.

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

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

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

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

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? Frequent.

 

Do you have or have you had weight gain recently? Yes.

How much have you gained? 75 lbs.

 

Do you have or have you had difficulty walking in the dark recently? Yes.

Do you have or have you had balance problems recently? Yes, in the dark.

Do you have or have you had new skin growths recently? Yes.

Do you have or have you had cold intolerance recently? Yes.

Do you have or have you had lymph node enlargement recently? Yes.

 

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

What are the other items of physical fitness you want to mention? Had

Epstein Barr in 20's, " mono " .

 

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

Who had diabetes in your family? Aunt, Grandmother.

 

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

Who had cancer in your family? Grandmother, Mother.

 

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

Who had gout in your family? Don't remember.

 

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

Who had heart trouble in your family? Grandfather.

 

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

family? Grandfather.

 

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

Who had asthma in your family? Self.

 

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

Who had glaucoma in your family? Father.

 

What medications do you currently take? Birth Control, Ibuprofen, Imodium.

 

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

them. Tonsils and adenoids at age 4 or 5.

 

End of Medical History portion.

 

 

Four Pillar Examination:

 

 

Observe:

 

Dry lifeless color indicates exhausted Stomach-Qi.

Fat body. Yes. (Central Obesity in Western Medicine terms. Damp Phlegm,

Spleen Qi and/or Kidney Yang deficiency.)

Clear thin phlegm, cold pattern.

Observe the lips. Dry, peeling, dull red. (Stomach Heat, Spleen Heat or

Spleen Yin deficiency with deficient heat)

Observe the gums. Receding gum line, has had grafts from roof of mouth

several times, so unpleasant she doesn't want to do it again. (Qi and Blood

deficiency, Stomach Fire, Kidney Yin deficiency with deficient heat)

Pale, sallow face, deficient qi & blood.

 

Tongue spirit: Like a fresh piece of meat - good spirit.

 

Tongue color.

Pale moist: Yang deficient.

 

Tongue shape.

Swollen: Phlegm or Damp.

Cracked: Yin Deficient

Short transverse on sides: Spleen Yin Deficient.

Teeth marks: Spleen Qi Deficient.

 

Tongue coating.

Thin with root: Healthy Stomach Qi.

 

Tongue patterns:

Spleen Qi Deficient: teeth marks or swollen on sides of center

section.

 

Inquire:

 

Gradual onset of headache. Yes. (Interior cause)

Time of day when the head aches. Middle of the day, lasts the rest of the

day. (Qi or Yang deficiency)

Location of the headache. Whole head. (Exterior Wind Heat or Kidney)

Character of the headache pain: Bursting. (Liver Yang rising)

Condition of the patient while having the headache. Ruins the day.

Gradual onset of dizziness. Yes, as a teen, 14 to 20 particularly.

Slight dizziness, worse when tired. Yes. (Liver Yang, Qi, Blood deficient,

Phlegm Damp)

Pain that is diminished by heat. Yes. (Cold condition)

Pain that is worsened by touch or pressure. Yes. (Excess)

Sharp stabbing pain usually in a fixed location. Yes, in her heels. (blood

stasis)

Sensation of heaviness. Yes, especially if she has a beer. (damp cold, damp

heat, qi deficiency or bi syndrome)

Dark Yellow or Reddish Urine. Yes. (Heat or Damp Heat)

Frequent watery or unformed stools. Yes. (Dampness)

Urgent diarrhea, especially if yellowish with burning anus. Yes, but only

if spicy food.

Stool dry at first, then wet. Yes, sometimes. (Retention of food in Stomach)

Not able to fall asleep. Yes. (Disturbance of Heart and Spleen Qi)

Dream disturbed sleep. Yes. (Disturbance of Heart and Spleen Qi or Liver

Fire Rising)

Restless sleep with dreams. Yes. (Disturbance of Heart and Spleen Qi)

Wake up early and not able to fall asleep again. Yes. (Gall Bladder deficiency)

 

Female section:

 

Sometimes early, sometimes late period. Yes, before Birth Control pills.

(Liver Qi stagnation, Liver Blood Stasis, Spleen deficiency, Kidney deficiency)

Heavy menstrual flow. Yes. (Qi deficient; Blood Heat; Liver Fire; Spleen,

Kidney Yang deficiency; Liver, Kidney Yin deficiency; Liver, Kidney Yin

deficiency with Blood Empty Heat; Blood Stasis in the Uterus)

Dark red or bright red menstrual blood. Yes. (Blood Heat)

Freshred color menstrual blood. Yes. (Empty Heat in the Blood)

Congealed menses with clots. Yes. (Blood Stasis in the Uterus, Blood Heat,

Cold in the Uterus, Qi deficiency)

Watery menses. Yes. (Qi deficiency, Blood deficiency, Cold Damp in the

Uterus, Spleen and Kidney Yang deficiency, Liver and Kidney Yin deficiency)

Pain before periods. Yes.(Liver Qi Stagnation)

Pain during periods. Yes. (Liver Qi Stagnation, Liver Blood Stasis,

Stagnation of Cold in the Uterus, Damp Heat in the Uterus, Stagnant Liver

Qi turning to Liver Fire, Deficient Qi and Blood, Spleen Yang and Liver

Blood deficiency, Liver and Kidney Yin Deficiency)

Taking contraceptive pills. Yes.

Have had two or more births. Yes. (Weaken the body)

White leucorrhea. Yes, all the time. (Cold from Spleen or Kidney Yang

deficiency or exterior Cold Damp)

Watery leucorrhea. Yes. (Cold Dampness, deficient)

Thick leucorrhea. Yes. (Damp Heat, excess)

Is it possible that you are pregnant now? No.

 

End of Female Section

 

Dry mouth is liver, kidney, yin deficiency, heat.

 

Listen & smell:

 

Sudden loss of voice. Yes, when sick. (usually wind heat)

Wheezing. Yes. (asthma due to kidney deficiency)

Heavy or sudden, violent cough. Yes. (excess)

Dry hacking cough. Yes. (heat or dryness)

Crying. Yes. (related to metal, lung deficiency) Two times per week gets

depressed.

 

Palpate:

 

Systolic blood pressure (Optimal <120; 124, Normal <130

Diastolic blood pressure (Optimal <80; 75 Normal <85

Heart rate. 80

 

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

Cold hands and feet. Yes. ( deficient yin, extreme pathogenic cold)

Dry skin. Yes. (deficiency of liver blood)

 

End of Case Record.

 

Your comments are invited, as always.

 

Regards,

 

Pete