Patient update-long

[Guest guest]

I presented this case sometime ago and wanted to update you on her progress.

Patient presented to my office on 6/1/00 with the following:

 

1) Chief complaint- 39 year old female with total hairloss2) Biomedical Dx and supporting lab tests- alopecia universalis3) Relevant Medical History-Three years ago patient went through about a month of a half where she had recurrent strep throat infections. She was treated repeatedly with antibiotics. After the strep subsided she had a severe flu-like illness. Several weeks into the illness, a tampon dislodged from her vagina. She was unsure how long it had been there, possibly two months. Her illness was attributed to Toxic Shock Syndrome. After the tampon came out she felt much better, but not long afterwards she lost all body head and body hair, and was given the Dx of alopecia universalis. Western doctors believe it to be an autoimmune related illness.

 

4) questioning examination-

The patient reported often having a low appetite, and nausea, which is exacerbated by stress and anxiety

Low thirst: has to force herself to drink most of the time

Digestion: Fluctuates with nervousness/stress, easily disrupted

BM: tend toward diarrhea with stress

Ears: tinnitus ever since illness, although it is decreasing now

Periods: no cramping, clotting

She has had two children, divorced a year ago, is dating now but is embarrased by her hairloss. Smokes, 2 cups coffee/day, was drinking 2-3 glasses wine/day but discontinued with recent prescriptionof Paxil, never cooks

Meds: Just began taking Paxil 20 mg/day- was having palpitations as s/e, she had tried other antidepressants but has had allergic reactions to them

 

5) pulse and palpation examination-R cun-tight, guan softchi small, L guan tight, slight, slight rapid overall

 

6) tongue and observation examination

Red edges, no fur on edge, red center with less fur

Dx: Liver invading Sp/St, Liv yin def

7) the pattern(s) and treatment principles you chose, including yourrationale - At the time

8) herbs used -She to take the first formula I prescribed because I gave it as a tea and she didn't like the taste.

Here is what I initially gave her: I use the Lotus powders. All amounts are in grams. This is a weeks prescription.

Chi Shao 5

Chuan Xiong 5

Tao Ren 5

Da Zao 5

Bai Shao 5

He Shou Wu 5

Niu Xi 4

Xiao Yao San 10

Qi Ju Di Huan Wan 10

 

9) other treatments or lifestyle changes-

I instructed her to stop drinking alcohol and coffee.

 

After input from the group her diagnosis was rightly changed to one of Liver Qi and Blood Stagnation. And her formula was changed to the following and encapsulated, size 0 caps 5 TID

Chi Shao 5

Chuan Xiong 5

Da Zao 7

Bai Shao 5

He Shou Wu 8

Xiao Yao 10

Dan Shen 5

Qiang Huo 3

Nu Zhen Zi 2

 

1 week later

she felt itchiness all over her body and began to feel some hair growing on her head.

Pulse:R cun slippery, guan bow, L guan small

Tongue: Red body less fur at front, thick at rear

Coninued with previous diagnosis

 

2 weeks later

Hair growth on head and arms, still feeling itchiness

continued with previous diagnosis

 

3 weeks 6/20/00- refilled herbal presciption didn't see her for evaluation

 

Patient stopped treatment without notification. I phoned her and she came in on 8/3/00

She reported she had had the flu and had severe diarrhea. She thought it was the herbs and stopped

taking them. After eliminating everything she discovered she was having a reaction to the Paxil she was taking.

She had stopped taking the herbs for about 1 month and the hair she was growing began to fall out.

She was still having difficulty with diarrhea.

Pulse: R guan soft, chi deep, L deep tight, slightchoppy overall

Tongue: Thich white fur at rear, red cracks in center

 

Previous diagnosis with Sp Qi def

 

Changed her formula to the following

Shen Ling Bai Zhu San 15

Chuan Xiong 5

Bai Shao 5

He Shou Wu 8

Dan Shen 5

Niu Zhen Zi 3

Wu Wei Zi 2

Sheng Di 2

Huang Qi 5

 

! week later, she refilled without evaluation and said her BM had stabilized. No mention of hairgrowth

 

 

I am hoping this patient will remain in closer contact should future problems arise. We were very excited by her initial hair growth.

 

Thanks,

 

Sean P. Doherty, M.Sc., M.S., L.Ac.Nashua Natural Medicine76 Northeastern Blvd., Unit 36ANashua, NH 03062ph(603) 579-0956fax(603) 579-0957Healthcare for the whole family...Naturally!