Guest guest Posted November 12, 2009 Report Share Posted November 12, 2009 Anybody want to take a stab at this? 19 yr old male, athletic build, 6'1 " , no remarkable past history. C.C.: Patient states that upon waking, he feels very " nauseous " , as if his stomach were being " turned inside out " . He immediately goes to his bathroom, and feels a great deal of saliva building up in his mouth and throat. As he attempts to expel these fluids, he experiences something like a gag reflex, and ends up vomiting clear fluid, streaked with yellow fluid. Sometimes, the fluids are streaked with blood; however, the patient thinks this blood is coming from the throat as a result of all the irritation--he doesn't think it is blood from the G.I. After vomiting, the patient states he experiences " some relief " . The sensation does not return at any other time throughout the waking hours. Modern dx has provided no explanation. No ulcers are present. It isn't know if testing for H. Pylori levels were conducted. Per the patient's account, glucose levels are normal, and there is no family history of diabetes. Modern Western practitioners have recommended OTC antacids, as needed. Tongue: Body red, some prickles (over entire body), red tip. Coat is white, greasy, thick, and extremely thick/greasy in lower jiao region. The tongue also looks as if candida is present. Pulse: Slippery overall, slightly rapid, deep in Kidney positions. Upon palpation of the channels, no abnormalities, or especially tender areas were discovered. Patient prefers cold drinks, stomach pain is worse with pressure, constant hunger (gnawing hunger), craves meat, pain somewhat alleviated by eating, no abdominal bloating, or any digestive complaints. BM are formed and light brown. Urine is clear. Patient has no extreme emotions, but states he feels some " stress " when thinking about the future. Other symptoms include alternating sensations of extreme heat, or extreme cold, in the feet. Patient's diet is highly varied, but doesn't contain many items that are spicy or acidic. On average, patient eats meals composed of a lean meat, a starch, and some vegetables. Patient enjoys eating, and enjoys experiencing a variety of foods, tastes, and flavors. Patient does not drink coffee, tea, sodas, or alcohol--mostly just water. My immediate reaction when hearing the initial symptoms was to think along the lines of Stomach heat/Yang Ming heat, due to the yellow fluids, and constant gnawing hunger. But, aside from the prickles on the tongue, and slightly rapid pulse, nothing else really supports this. Yet, this guy ends up having a lot more cold signs, and phlegm signs, which I just don't associate with " gnawing hunger " . I started also considering the role of food stagnation, due to the thick coat, and slippery pulses--but, there just aren't any digestive complaints, and no bloating, gas, or distension. Since there isn't any anger of severe frustration, it doesn't even seem possible to contemplate a " wood overacting " dx. And then, where are we getting all these cold phlegm sign from? Not much in his diet (as he described it to me), are really phlegm generating foods. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 12, 2009 Report Share Posted November 12, 2009 Off the cuff, it sounds like timid gallbladder. Deficiency in courage, resulting in counterflow of bile (yellow streaks),and light colored stools. Life experience will tonify confidence. Janis Egan Sent from my iPhone On Nov 11, 2009, at 8:34 PM, " ariaksatri2 " <aryaksatriya wrote: Anybody want to take a stab at this? 19 yr old male, athletic build, 6'1 " , no remarkable past history. C.C.: Patient states that upon waking, he feels very " nauseous " , as if his stomach were being " turned inside out " . He immediately goes to his bathroom, and feels a great deal of saliva building up in his mouth and throat. As he attempts to expel these fluids, he experiences something like a gag reflex, and ends up vomiting clear fluid, streaked with yellow fluid. Sometimes, the fluids are streaked with blood; however, the patient thinks this blood is coming from the throat as a result of all the irritation--he doesn't think it is blood from the G.I. After vomiting, the patient states he experiences " some relief " . The sensation does not return at any other time throughout the waking hours. Modern dx has provided no explanation. No ulcers are present. It isn't know if testing for H. Pylori levels were conducted. Per the patient's account, glucose levels are normal, and there is no family history of diabetes. Modern Western practitioners have recommended OTC antacids, as needed. Tongue: Body red, some prickles (over entire body), red tip. Coat is white, greasy, thick, and extremely thick/greasy in lower jiao region. The tongue also looks as if candida is present. Pulse: Slippery overall, slightly rapid, deep in Kidney positions. Upon palpation of the channels, no abnormalities, or especially tender areas were discovered. Patient prefers cold drinks, stomach pain is worse with pressure, constant hunger (gnawing hunger), craves meat, pain somewhat alleviated by eating, no abdominal bloating, or any digestive complaints. BM are formed and light brown. Urine is clear. Patient has no extreme emotions, but states he feels some " stress " when thinking about the future. Other symptoms include alternating sensations of extreme heat, or extreme cold, in the feet. Patient's diet is highly varied, but doesn't contain many items that are spicy or acidic. On average, patient eats meals composed of a lean meat, a starch, and some vegetables. Patient enjoys eating, and enjoys experiencing a variety of foods, tastes, and flavors. Patient does not drink coffee, tea, sodas, or alcohol--mostly just water. My immediate reaction when hearing the initial symptoms was to think along the lines of Stomach heat/Yang Ming heat, due to the yellow fluids, and constant gnawing hunger. But, aside from the prickles on the tongue, and slightly rapid pulse, nothing else really supports this. Yet, this guy ends up having a lot more cold signs, and phlegm signs, which I just don't associate with " gnawing hunger " . I started also considering the role of food stagnation, due to the thick coat, and slippery pulses--but, there just aren't any digestive complaints, and no bloating, gas, or distension. Since there isn't any anger of severe frustration, it doesn't even seem possible to contemplate a " wood overacting " dx. And then, where are we getting all these cold phlegm sign from? Not much in his diet (as he described it to me), are really phlegm generating foods. --- Subscribe to the free online journal for TCM at Times http://www.chinesemedicinetimes.com Help build the world's largest online encyclopedia for Chinese medicine and acupuncture, click, http://www.chinesemedicinetimes.com/wiki/CMTpedia and adjust accordingly. Please consider the environment and only print this message if absolutely necessary. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 12, 2009 Report Share Posted November 12, 2009 Hi; The first thing is that there are only a few basic dynamics for vomiting: deficiency, external pathogenic factors, and obstruction. He is young with no history, so that leaves only EPF and obstruction. Double check for EPF. Obstruction can be Qi, Phlegm or Food (at this basic level). You said he has mild worries about the future, so no qi obstruction then. So, it looks like phlegm or more likely food, considering that he seems to have an unreasonable appetite. So food obstruction is the most likely. But... Then we look at the vomiting: Morning, lots of saliva, clear vomitus with some yellow, and *experiences relief*. ...And NO food vomitus. Morning in this case means yang qi is deficient. Lots of saliva and clear vomitus mean damp and cold. Yellow means Spleen. Experiences relief means EXCESS. No food vomitus means that damp and cold obstruction take precedence over food obstruction. So it's either damp, cold or food obstruction. The heat signs (tongue body red) are not supported in the presentation of the vomiting, and you might want to go into more detail with those (how long have you had unreasonable hunger? etc). For me, it looks like an overstrong stomach, a deficient spleen ( " pain somewhat alleviated by eating " ), and excess damp and cold obstructing the middle jiao. Anyway, whenever you find you are having a tough time extracting a more complete picture from a person, your number one rule is analyse the **** out of the presenting complaint, this will lead you to other clues. For instance, we're missing a lot of information on the vomiting: What time in the morning does this happen? I mean, exactly. And does this vary, and what is the range of variance. What is the sound like when he vomits? What does he taste when he vomits? What does the vomitus smell like? Does he _ever_ vomit up material? What is the consistency of the vomitus? All we know is the colour. The times just prior to and following the presenting complaint are also important: What does he feel like right upon waking? Are his feet cold or hot? Are his covers on or off? Does he have pain (perhaps perceived as mere discomfort by a 19 year old male) in the abdomen upon waking? A sense of fullness / coldness / whatever? Where is it? What position is he in when he wakes? Side, front back? Are his eyelids swollen, does he have phlegm in his eyes, does he have mucous running from his nose, shivers and chills, weakness of his limbs or hands? Then there are other big clues that we are missing. Do his bowel movements have a strong odour or not? How long have the hot and cold feet been going on? You mentioned that he had pain - where is it, how long is it there for, what is its character, its intensity? No one wakes up and vomits in the morning without feeling something beforehand! However, people often have very little awareness placed on themselves since we think the answers are on a sheet with blood values on it. Crush the answers out of them! Triturate the last little bit of information out of their interview! Be intrusive with your questioning - it's your job! Good luck, Hugo ________________________________ Hugo Ramiro http://middlemedicine.wordpress.com http://www.middlemedicine.org ________________________________ C.C.: Patient states that upon waking, he feels very " nauseous " , as if his stomach were being " turned inside out " . He immediately goes to his bathroom, and feels a great deal of saliva building up in his mouth and throat. As he attempts to expel these fluids, he experiences something like a gag reflex, and ends up vomiting clear fluid, streaked with yellow fluid. Sometimes, the fluids are streaked with blood; however, the patient thinks this blood is coming from the throat as a result of all the irritation-- he doesn't think it is blood from the G.I. After vomiting, the patient states he experiences " some relief " . The sensation does not return at any other time throughout the waking hours. Modern dx has provided no explanation. No ulcers are present. It isn't know if testing for H. Pylori levels were conducted. Per the patient's account, glucose levels are normal, and there is no family history of diabetes. Modern Western practitioners have recommended OTC antacids, as needed. Tongue: Body red, some prickles (over entire body), red tip. Coat is white, greasy, thick, and extremely thick/greasy in lower jiao region. The tongue also looks as if candida is present. Pulse: Slippery overall, slightly rapid, deep in Kidney positions. Upon palpation of the channels, no abnormalities, or especially tender areas were discovered. Patient prefers cold drinks, stomach pain is worse with pressure, constant hunger (gnawing hunger), craves meat, pain somewhat alleviated by eating, no abdominal bloating, or any digestive complaints. BM are formed and light brown. Urine is clear. Patient has no extreme emotions, but states he feels some " stress " when thinking about the future. Other symptoms include alternating sensations of extreme heat, or extreme cold, in the feet. Patient's diet is highly varied, but doesn't contain many items that are spicy or acidic. On average, patient eats meals composed of a lean meat, a starch, and some vegetables. Patient enjoys eating, and enjoys experiencing a variety of foods, tastes, and flavors. Patient does not drink coffee, tea, sodas, or alcohol--mostly just water. My immediate reaction when hearing the initial symptoms was to think along the lines of Stomach heat/Yang Ming heat, due to the yellow fluids, and constant gnawing hunger. But, aside from the prickles on the tongue, and slightly rapid pulse, nothing else really supports this. Yet, this guy ends up having a lot more cold signs, and phlegm signs, which I just don't associate with " gnawing hunger " . I started also considering the role of food stagnation, due to the thick coat, and slippery pulses--but, there just aren't any digestive complaints, and no bloating, gas, or distension. Since there isn't any anger of severe frustration, it doesn't even seem possible to contemplate a " wood overacting " dx. And then, where are we getting all these cold phlegm sign from? Not much in his diet (as he described it to me), are really phlegm generating foods. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 12, 2009 Report Share Posted November 12, 2009 1) any hx of head trauma, concussion, whip-lash, etc..? given the athletic background, head injury is important to r/o. (sx showing up upon waking can be related to head/neck/pillow position? pressure on vomiting center of medulla? just a thought to consider.) 2) how is patient's hydration/electrolyte status? nausea and impaired body temp regulation are seen when there is 5% dehydration. (*aside* patient can drink " Yin-Yang " water -- half boiling hot water, half almost freezing cold water, mixed together, has energetic effect of Xiao Chai Hu Tang...) head injury and dehydration are both such common issues in young sports persons, best to r/o before going down tcm diff-dx... ~e -- Edith Chan, L.Ac. Doctoral Fellow www.DanTianWellness.com Office: 415.668.1880 - Mobile: 415.298.5324 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 12, 2009 Report Share Posted November 12, 2009 Hi Edith! The patient was not reported to have any head pain, heavy fatigue, problems with memory or concentration. Concussions usually present with liver pathology as well. What is your experience with " hidden " pathology for concussions? I have not seen anyone with concussion that did not have easily discoverable s & s. I disagree with the idea of waiting before proceeding with TCM diff - injuries are part of the TCM diff and shoudl be picked up in the interview. Again, recent or severe concussions show up in either in the s & s or in the history, and are well treated by . Thanks, Hugo ________________________________ Hugo Ramiro http://middlemedicine.wordpress.com http://www.middlemedicine.org ________________________________ " Edith Chan, L.Ac. " <chineseherbs Chinese Medicine Thu, 12 November, 2009 0:45:30 Re: Dx question/many mixed symptoms 1) any hx of head trauma, concussion, whip-lash, etc..? given the athletic background, head injury is important to r/o. (sx showing up upon waking can be related to head/neck/pillow position? pressure on vomiting center of medulla? just a thought to consider.) 2) how is patient's hydration/electroly te status? nausea and impaired body temp regulation are seen when there is 5% dehydration. (*aside* patient can drink " Yin-Yang " water -- half boiling hot water, half almost freezing cold water, mixed together, has energetic effect of Xiao Chai Hu Tang...) head injury and dehydration are both such common issues in young sports persons, best to r/o before going down tcm diff-dx... ~e -- Edith Chan, L.Ac. Doctoral Fellow www.DanTianWellness .com Office: 415.668.1880 - Mobile: 415.298.5324 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 13, 2009 Report Share Posted November 13, 2009 " Edith Chan, L.Ac. " wrote <<1) any hx of head trauma, concussion, whip-lash, etc..?>> No, no history of head/neck trauma. No contact sports. Edith Chan <<2) how is patient's hydration/electrolyte status? nausea and impaired body temp regulation are seen when there is 5% dehydration.>> A possible element that might be involved. Edith wrote <<(*aside* patient can drink " Yin-Yang " water -- half boiling hot water, half almost freezing cold water, mixed together, has energetic effect of Xiao Chai Hu Tang...)>> This has to be one of the most interesting things I've heard all week; where did you learn about this " yin/yang " water? The same energetic effect of Xiao Chai Hu Tang?--I'm going to have to experiment with this myself. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 15, 2009 Report Share Posted November 15, 2009 I adore this kind of case study as it exempifies the edge of Chinese medicine, treating difficult cases that no explanation can be traced by our western medicine counterpart. This is actually not considered 'rare' because it is quite common and I have sent it before. It however, takes long time to recover (more than 1 month). Some symptoms I expected are not stated here. They include fatigue, shortness of breath, feeling nausea when brushing teeth with cold water in the morning etc. It is a stomach issue and the nature is deficient cold. It can be classified as gastritis or inflammation in the throat(pharynx). A typical formula can be found in line14, Chpt 6 Chest Impediment and Taxations, Jin Gui Yao Lue,Hu & aacute;ng Q & iacute; Ji & agrave;n Zh & #333;ng T & #257;ng (Astragalus Center-Fortifying Decoction)can be used as base formula. The formula matches the pathomechanism of this case. Line14 For deficiency taxation, abdominal urgency, and the various kinds of insufficiency, Hu & aacute;ng Q & iacute; Ji & agrave;n Zh & #333;ng T & #257;ng (Astragalus Center-Fortifying Decoction) is indicated. Add 1 1/2 liang of hu & aacute;ng q & iacute; (Radix Astragali) to Xi & #259;o Ji & agrave;n Zh & #333;ng T & #257;ng (Minor Center-Fortifying Decoction), and follow the above preparation method. With shortness of breath and fullness in the chest, add sh & #275;ng ji & #257;ng (Rhizoma Zingiberis Recens). With abdominal fullness, remove d & agrave; z & #259;o (Fructus Jujubae) and add 1 1/2 liang of f & uacute; l & iacute;ng (Poria). For treating patterns of lung deficiency, detriment, and to supplement qi, add 3 liang of b & agrave;n xi & agrave; (Rhizoma Pinelliae). TEXT NOTE Various kinds of insufficiency: deficiencies of qi, blood, yin, or yang. ANALYSIS This line discusses the patterns and treatment of yin and yang dual deficiency with predominant signs of spleen qi deficiency. This pattern includes all of the deficiency signs as mentioned in the previous line, with abdominal urgency attributed to internal damage resulting from taxation. Manifestations include palpitations, nosebleed, abdominal pain, dream emission, soreness and pain of the four limbs, vexing heat of the palms and soles, and dryness of the mouth and pharynx. The addition of hu & aacute;ng q & iacute; (Radix Astragali) suggests there also must be predominant signs of qi deficiency such as spontaneous sweating, night sweats, aversion to wind, shortness of breath, and fatigue. Treatment includes middle-warming and deficiency-supplementing methods, and Hu & aacute;ng Q & iacute; Ji & agrave;n Zh & #333;ng T & #257;ng (Astragalus Center-Fortifying Decoction) is the selected formula. Hu & aacute;ng q & iacute; (Radix Astragali) acts to boost the qi-supplementing and spleen-warming actions of Xi & #259;o Ji & agrave;n Zh & #333;ng T & #257;ng (Minor Center-Fortifying Decoction). COMMENTARY This formula can also effectively treat stomach pain associated with patterns of spleen-stomach deficiency cold. (subtraction from the book, Understanding the Jin Gui Yao Lue, A Practical Textbook, Peoples Medical Publishing House, Sept 2009 by Sung, Yuk-ming, Edited by Harry Lardner) Besides base formula, remove ginger, lessen gui zhi (cinnamon twig), and add huang lian (coptis), wu zhu yu (evodia), gao liang jiang (lesser galangal, Alpiniae Officinarum Rhizoma) and some qi-rectifying medicinals. Hope to see some feedback of the patient. My 2 cents, Sung, Yuk-ming Phd (Chengdu U TCM), BA (Houston), L Ac (Hong Kong) Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.