New case, hip pain

[Guest guest]

Hi Everybody!

 

Comments, discussion and suggestions invited!

 

He gave me a report from a western MD that indicated High EOS, Low DHEA,

Abnormal EKG (heart murmur) and a BMI of 25.54. The MD recommended more

water, EDTA detox monthly and a hip replacement. The patient mainly cares

about the hip pain, hasn't followed up on the other recommendations wishing

to try TCM first.

 

Patient: male Record 11-22-4

 

Patient number: Date of birth: (age 77)

 

What is your major complaint? Hip injury, osteo arthritis - can’t put on a

sock, can’t tie a shoe, only wins half of his tennis games.

How long have you had this condition? 1 ½ years.

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

Master. A previously consulted acupuncturist prescribed Yunnan Pai Yao,

perhaps for cramps, but he does not remember a lot about it. He took 2 or 3

of the pills and still has the rest of the package.

 

Have you seen a Western Doctor for this condition? Yes, advised to get hip

replacement.

Have you ever had scarlet fever? Yes.

Have you ever had sinusitis? Yes, a long time ago.

Have you ever had a heart murmur? Yes.

Have you ever had a heart condition? Yes, aortic stenosis.

Have you ever had stomach, liver or intestinal trouble? Yes, hepatitis from

infected clams, 1967.

Have you ever had jaundice? Yes, from the hepatitis.

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

Have you ever had a tumor, growth, cyst or cancer? Yes, squamous cell

cancer removed from bridge of nose, 1993.

Have you ever had sugar or albumin in your urine? Yes, traced to too much

orange juice.

Have you ever had exposure to tuberculosis? Yes, probably, being a world

traveler.

Have you ever had to wear eyeglasses? Yes.

Have you ever had eye trouble? Yes, cataracts, sties.

Have you ever had ear, nose or throat trouble? Yes, strep throat, ears

lanced at age 6.

 

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

Have you ever had or do you now have swollen ankles? Seldom, left only.

Have you ever had or do you now have high blood pressure? Seldom, maybe 125.

Have you ever had or do you now have leg cramps? Seldom, usually left calf.

Have you ever had or do you now have a cough? Seldom, used to - 1 ½ year

treated by Jim Reese.

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

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

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

Have you ever had or do you now have pneumonia? Seldom, when 18 years old

had it.

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 constipation? Seldom.

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

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

had a colonoscopy and one polyp removed some time ago.

Have you ever had or do you now have increased appetite? Seldom, if very

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

active in high temperature.

Have you ever had or do you now have skin ulceration? Seldom.

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

Have you ever had or do you now have a rash? Seldom, had measles as a child.

Have you ever had or do you now have back pain? Seldom, wrenched back in 1964.

Have you ever had or do you now have frequent urination? Seldom.

 

(male only section)

Have you ever had or do you now have loss of sexual potency? Seldom.

(end of male only section)

 

Have you ever had or do you now have arthritis? Seldom, right pinkie and

right hip.

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? Frequent.

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

Have you ever had or do you now have backaches? Seldom, yoga helps.

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

Have you ever had or do you now have fever? Seldom, malaria in 1980.

Have you ever had or do you now have chills? Seldom, malaria in 1980.

Have you ever had or do you now have night sweats? Seldom.

Have you ever had or do you now have headaches? 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 smoke? Quit 20 years ago.

Do you have or have you had a memory defect recently? Yes.

Do you have or have you had ringing ears recently? Yes.

Do you have or have you had a change in your vision recently ? Yes,

cataract surgery, now needs glasses to read fine print.

Do you have or have you had new skin growths recently? Yes, little black

spot over his eyebrow.

Do you have or have you had a change in the color of your skin recently? Yes.

Do you have or have you had a tendency to bruise easily recently? Yes.

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

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

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

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

What medications do you currently take? No western medicines, vitamins

including C.

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

them. Tonsils at age 6, Hernia at age 37 and 39 (first one side then the

other), bullet wound at age 42 (Vietnam), cataract surgery at 72 and 73

(first one side then the other)

 

Observe:

 

Unhealthy complexion. Yes or No. (no spirit) Borderline.

Dark or unclear face color. Yes. (no spirit)

Slow or no movement. Yes. (deficient cold, usually spleen)

Dry lifeless color (indicates exhausted Stomach-Qi)

Red color (may indicate Inflammation, fever or infection) He has been in

the sun, however.

5' 9 1/4 " tall.

Round face and body with a long spine, slightly lazy, " Water Type " . Yes.

Fat body. Yes.

The eyes have glitter and reveal inner vitality. No, dull bloodshot eyes.

Observe the gums. Has had gum surgery.

Red face, heat in the blood; but he has been in the sun.

Pale nails. Yes, blood deficiency, liver and spleen.

Tongue color. Purple - crimson.

Tongue shape. Broad, but not swollen.

Tongue coating. Yellow flecks with many cracks.

Tongue moisture. Normal.

 

Gradual onset of headache. Yes, had such a headache a long time ago.

Location of the headache. Occiput.

Character of the headache pain: Dull.

Condition of the patient while having the headache. Annoyed, by the headache..

Sudden onset of dizziness. No, might get dizzy on a roller coaster.

Pain that is diminished by cold. Yes. (heat)

Pain that is relieved by touch or pressure. Yes. (deficient)

Pain that is worse in humid weather. Yes. (dampness)

Sharp stabbing pain usually in a fixed location. Yes. (blood stasis) If he

tries to tie his shoe.

Pain that moves from place to place. Yes. (wind) Pain does move a little.

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

Clear Urine. Yes, if he forgets his vitamins, otherwise it is yellow.

Dark Yellow or Reddish Urine. Yes.

Scanty urination. Yes, only if UTI.

Frequent dark, scanty and painful urination. Yes, not now, but 7 years ago.

Thirst, appetite and tastes. Sometimes he craves black licorice.

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

Change in sinews, such as weak or stiff. Yes. Fell in Australia, slipped on

wet stones.

Change in blood vessels. Yes, spider veins.

Change in the skin, such as flaccid skin. Yes.

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

 

Listen & smell:

 

No remarkable symptoms or signs in this section.

 

Palpate:

 

Systolic blood pressure (Optimal <120; today it is 108, quite low.

Diastolic blood pressure (Optimal <80; today it is 63, quite low.

Heart rate. Today it is 71.

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

Dry skin. Yes. (deficiency of liver blood)

Withered skin. Yes. (fluids are exhausted)

 

Summary: Complexion and face color suggests “No Spirit”. Slow movement

suggests deficient cold, usually Spleen. Dry lifeless color indicates

exhausted Stomach-Qi. Central weight gain is a risk factor for diabetes.

Dull eyes indicate either long standing emotional problems or poor general

health. Red face, heat in the blood; but he has been in the sun. Pale nails

are a sign of blood deficiency of the liver and spleen. Tongue color:

Purple - crimson - blood stasis derived from a heat condition. Tongue

coating: Yellow flecks with many cracks - heat, stomach yin deficiency.

Pain that is diminished by cold, indicates a heat condition. Pain that is

relieved by touch or pressure, indicates a deficient condition. Pain that

is worse in humid weather indicates a dampness condition. Sinking pulse,

yin, internal disharmony or obstruction. Withered skin, fluids are

exhausted. Pain that moves from place to place, wind. Slight pain with

fatigue, deficient qi or dampness.

 

Acupuncture impression: Condition is deficient, one cold sign, three heat

signs, a wind sign and a dampness sign. Stomach qi, Spleen blood, Liver

blood and fluids are all deficient. There is also a sign of blood stasis.

 

Treatment principle: Tonify deficiency, Calm the shen, move blood, clear

heat, regulate fluids and relieve pain.

 

Possible Points: Sp 6; St 36; LI 4, 11; L 7; Ashi.

 

Herbal Pills: Tonic: Liu Wei Di Huang Wan 12D1-5; Calm shen: An Mien Pien

8C1-1; Cholesterol reducing select from Jiang Ya Wan 7B1, Maodungching

8A1-4, Dan Shen or Styrax formulas 8A2, Heart Phlegm pills 8B or Weight

reduction pills 11E. Numbers refer to new Fratkin book listings.

 

Regards,

 

Pete