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case submission - hep c retro

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1) Chief complaint - ascites, abdominal swelling

 

2) Biomedical Dx - hep c, liver cirrhosis on ultrasound, elevated liver

enzymes

 

3) Relevant Medical History, include habits, diet, exercise, etc. -

brief hx of IV drug use in early seventies, good diet now, but smokes,

overworked, sedentary, was overweight before wasting set in

 

4) questioning examination (subjective)

 

fatigue, itchy rashes, diarrhea, bloating, leg twitches and cramps,

extremely cold, gaunt, ashen complexion, low appetite, spider nevi on

abdomen, depressed, no sex drive, hard abd. swellings (hepato and

splenomegaly)

 

5) pulse and palpation examination (objective)

 

wiry, slippery, but weak in chi both sides

 

6) tongue and observation examination (objective)

 

normal size purple body with cracks and thick yellow, greasy coat

 

7) the pattern(s) and treatment principles

 

dampheat - rashes, tongue coat, pulse

 

qi and blood stasis - hard swellings, tongue body and pulse, spider

nevi, cirrhosis, bloating

 

qi, blood, yin and yang xu - fatigue, leg twitches and cramps,

complexion, diarrhea, low app., coldness, etc.

 

8) herbs used (plan) -formulae varied, but generally centered on these

herbs

 

dan shen, hou po, hong hua, dang gui, dang shen, rou gui, bai shao, ku

shen, che qian zi, bai zhu, huang qin, chai hu

 

9) other treatments or lifestyle changes

 

decreased smoking. discontinued herbs and began acupuncture with

someone else about a month before he died

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