unusual cases

[Guest guest]

I treat a lot of unusual cases. Just helped a day trader with

episcleritis, a severe inflammation of the sclera of the eye. He

responded well to long dan xie gan tang and is maintained on dan zhi

xiao yao san. He had no luck with an opthalmologist, who just gave him

steroid creams. He was classic liver fire. Glad I saw him before he

snapped like the guy in Atlanta.

 

Now I have a patient with a burning painful tongue. I have treated this

before, but things are not going quickly this time. I usually begin my

search for the answer to such puzzles in Sionneau's series of treatment

books. The patient had a thick greasy tongue coat on a thin, reddish

body and he complained of plum pit qi. Sionneau sugested huang lian wen

dan tang which seemed good. However, the patient's condition worsened.

I sometimes see this with ban xia, so I decided that I would just clear

heat from the mouth and not focus on phlegm transformation. The patient

was robust and athletic, at first glance. Spicy herbs can exacerbate

subjective heat symptoms sometimes, I find.

 

Sionneau also recommended qing wei san for burning tongue. I tried qing

wei san for heart and stomach fire, with some components of si ni san to

try and address the liver qi stag and phlegm without spicy herbs. Still

no noticeable effect. Still convinced that the liver is at the root of

this case, I switched to long dan xie gan tang. This way I can address

the liver with chai hu and clear the heat directly from the root

channel. Thus, if the stomach and heart are the branch, they don't seem

to be the root. Long dan seems to give relief at first, but the patient

relapses while still taking the herbs.

 

The patient comes in for a follow up visit and I notice that he wears a

knee brace as he is in shorts. He usually wears a cap, but today I

notice his hair is kind of thin and graying. In his chart, I see that

he is 41, four years older than me, but he looks 15 years older. While

he has no symptoms of yin xu, I suspect he may be more xu than I

thought.

 

His tongue symptom came on slowly and began as a dry tongue, it turns

out. He overexercises, as well. Reasoning now that the patient also

has a yin xu component, I decide to shift gears. Several things lead me

to yu nu jian. This treats glossitis from ascending fire. Qing wei san

does not descend fire, so it would not work. Chai hu would not help

either and this could explain why the spicy herbs actually caused an

exacerbation. I knew it was heat, just not xu heat.

 

Now it turns out that the most common cause of burning tongue without

inflammation is diabetes. Yu nu jian is used for diabetes

coincidentally. Perhaps his plum pit qi is due to concomitant liver yin

xu affecting the throat.

 

The issue this case raises for me is making the yin xu diagnosis. I

think yin xu is much overdiagnosed and I see much less of it than

textbooks would seem to suggest. I try not make a yin xu dx on a hunch,

but look for supporting s/s. However, in case like this, the signs are

subtle. The patient's age, wiry (not athletic, really) appearance,

chronic knee pain, slow onset and chronicity of illness, possibility of

diabetes and very thin flat tongue body were all. No nightsweats, low

back pain, five heart heat, thirst, dryness, restlessness, etc.

 

The pulse was wiry, a little slippery and the thick tongue coat caused

me to focus on excess. I usually see excess cases of this type get

symptom relief within a day or two. I gave the patient 3-5 day batches

of herbs. I changed or modified formulae more frequently than usual in

response to adverse effects or lack of change. The patient had just

been raked over the coals by a food allergy lab and I was sensitive to

this.

 

1) Should I have been able to dx yin xu earlier on? How?

 

2) Should I have continued with an excess formula for longer periods of

time?

 

thanks

 

 

[Guest guest]

I think your original DX was reasonable based on the sxs that

appeared. I think there's a lot more Lv yin xu out there than sxs may

show (in my experience). As soon as the exacerbation occured w/ the

excess herbs, i would have switched to Yi Guan Jian or, as you did, yu

Nu Jian. Nice Move!

 

Mark

[Guest guest]

Mark,

 

Yi guan jian was my other choice, but I decided to focus on patients

symptoms, which seemed more well addressed by yu nu jian. I definitely

thought that the liver seems to be involved because of the plumpit qi,

though it may not be the root. Definitely liver and heart involvement,

but not sure about kidneys.

 

While sionneau lists several patterns for plumpit, they all involve the

liver. Yi guan jian is the best choice for this symptom and I would

have probably chosen it if plumpit was the chief complaint. I toyed

with combining the two, but decided to modify yu nu jian instead to more

strongly address the glossitis. I still await the results of this

intervention.

 

I do have one stumbling block, though. I have the patient on granules,

but he wants to switch to pills. Who makes a yu nu jian pill or should

I just use zhi bai di huang wan after symptoms start to subside. At

that point, it would perhaps be more appropriate to focus on the root

anyway.

 

Oh yeah, I sent the patient for a blood sugar test. Did you hear that

a longtime oregon L.Ac. just lost his license because he exceeded his

scope of practice. BME is most concerned about proper referral. This

past month, I caught a blood clot in a patient with a muscle spasm.

However, last year, several colleagues really dropped the ball on a 30

year old fibromyalgia patient. She turned out to have bone cancer which

should have been caught 15 months earlier witha very basic $20 blood

test. The patient now has no chance for survival, but her odds would

have been much greater before the cancer spread to every bone in her

body. If a patient has any symptoms that have not been medically

diagnosed and those symptoms persist or worsen, cover your butt and make

a referral and chart it.

 

 

[Guest guest]

Thanks for the reminder on proper referrals Todd. I believe that Mayway

now carries a plumflower brand Yu Nu Jian Pill.

 

Mark