Case Hx - Request for Assistance

[Guest guest]

25 y.o. Female college student

 

First presented 10/00 w/ c/o leg pain for which she was successfully

treated w/ acupuncture. She also presented w/ anxiety and insomnia so

I encouraged her to consider herbal therapy to which she consented.

 

Past Medical Hx: Remarkable for low back pain, neck pain, migraine

headaches, IBS, asthma, TMJ, tinnitus, duodenal ulcer (as child, now

gastric reflux), anxiety and depression (PTSD due to childhood abuse

which has carried over into early adult relationships). She is taking

Elavil (previously Zoloft, Paxil - 2 yr hx), Buspar, Tavis-D, Clartin-

D, a nasal inhalant and birth control pill. She is seeing a counselor

every other week which seems to be helping her in her healing

process. Her mestrual periods were very irregular (long time between)

prior to taking birth control pills. She describes her menses as dark

and clotty with cramping prior to and during menses.

 

Current c/o: Decreased appetite (only able to eat small amounts of

chicken, oatmeal and bland things), abdominal cramping and diarrhea

(unlike her previous IBS sx). She is cold all of the time (denies

sweating). Her sleep continue to be poor (she previously had def heat

signs at noc, but not now). She is very fatigued w/ dizziness and

tinnitus. Her anxiety has increased with this. She has what she

calls " flashbacks " which result in her behaving as a child for

several minutes until she can work through the emotions. She also

becomes reclusive for several hours at a time.

 

Her pulse is thin and rapid (approx 110 bpm). Her tongue is dark

(red/purple, seems more purple to me) with an unrooted greasy yellow

coat in the spleen area (medial sides, no coat in center or

elsewhere). Her hands are very cold to the touch, feet also cold, but

not as cold as hands. Her facial complexion is pale and lusterless.

 

In the past, she was clearly yin deficient w/ heat. She went home for

the holidays and returned yesterday with the above presentation. I

believe she has deficiency of Spleen Yang, Liver Qi stagnation,

Heart/Liver blood deficiency, Yin deficiency...

 

I would like to get a more cohesive Dx of root and branch. This was a

much clearer picture to me before the cold sx became prominant. The

disappearance of the heat symptoms perplexes me as the signs (tongue

and pulse) are still there.

 

I am unsure of a strategy to treat both the spleen yang and disturbed

shen as most of the basic spleen formulas warn of caution in cases of

deficiency heat.

 

Your thoughts are appreciated.

[Guest guest]

Michael,

From the signs and symptoms you have presented, there

seems to be some evidence of Liver depression with

heat, blood stagnation in the lower jiao. I have a

question with the spleen yang - is her whole body

cold, limbs, or just hands and feet? And what type of

diarrhea is it - loose, food present, watery, or loose

foul odor and burning? she does seem to have a little

bit of everything. I think that even though you don't

see as much heat as you did in the past, the tongue

and pulse both appear to show some depressive heat,

possibly in the liver and maybe yang ming.

 

It would be interesting to know which of her

complaints started first and how they progressed

through childhood into adulthood. If the abuse

occurred young, the digestive disturbance may be

closely correlated with that. And so possibly seeing

that as a root and looking at herbs to warm and open

the bao luo and invigorate blood, regulate qi in the

lower jiao, and calm and settle spirit would be

beneficial to her.

 

I've worked with many abused woman experiencing

flashbacks, and they seem to present as a type of

counterflow; they quickly arise from deep within. I'm

not sure on how to relate the regression part of it in

TCM terms. Therapy and needles, using points focused

on the Chong and possibly Dai mai really facilitate

the movement and release of these memories. However,

they can also be too moving and so if you work with

her, you'll need to speak with her therapist so the

three of you can schedule sessions together.

 

I guess I'm not clear on seeing a predominance of

spleen yang signs (fatigue, dizziness, diarrhea, poor

app, cold body?). This could be b/c i'm not fully

understanding the details of her s/s. If she only has

cold in her hands and feet, it could be the liver

depression and not spleen yang. Also, if there is this

damp component, is the dizziness and tinnitus due to

clear yang not reaching the head or is it from a yin

xu of kidney, blood xu, or liver yin xu with yang

rising? Is the tinnitus loud pitch and acute or a

dull constant pitch? Does she get dizzy when she

stands or after a long day or is it sudden when she

gets upset or emotional? And could you say a little

more about her sleep. If she has trouble falling

asleep; staying asleep; any dreams, flashbacks

predominantly at night if most of the abuse took place

then; nightsweats; does she wake up early; is she

afraid? I would be interested in knowing.

 

Depending on if you see mostly cold signs below

(possibly cold and blood stasis in Lj evidenced by

painful dark menses with clots, prolonged cycle,

diarrhea if due to cold) with deficiency in the

middle, and heat above (if the disturbed sleep,

dizziness and tinnitus are due to heat), then a

formula like

 

wu mei wan; mume pill (p.466 in Bensky formulas) is

known for a jue yin pattern of cold below, deficiency

in the middle and heat above. Some of the s/s are

intermittent attacks of abdominal pain, a stifling

sensation , irritability, and warmth in the chest and

epigastrium accompanied by vomiting after eating, and

cold hands and feet. Also useful for addressing

chronic diarrhea with a mixture of heat and cold and

weakended normal qi. s/s include diarrhea, abdominal

pain that responds favorably to warmth, borborygmus,

and a red tongue with white coating. CI for damp heat

diarrhea (wu mei, chuan jiao, xi xin, huang lian,

huang bai, gan jiang, fu zi, gui zhi, ren shen and

dang gui)

 

I'm looking at this formula as perhaps a model to base

her treatment on.

 

One more thing that struck me was the myriad of

medications she's taking. I haven't been able to look

them all up yet, but check them to see if they could

possibly be enhancing her symptoms, changing the pulse

and tongue possibly. Elavil is worth noting and it

usually comes with digestive disturbances. How long

has she been on Claritin (love that commercial),

Tavis-D, and the OCP is going to effect the

reproductive system. I'm not familiar with Buspar,

but she's doing a number on her digestive tract.

 

I don't doubt that she has deficiency in the middle

with possibly some damp heat. Let me know what you

think.

 

Thanks, Kim

--- Michael Buyze <mbuyze wrote:

> 25 y.o. Female college student

>

> First presented 10/00 w/ c/o leg pain for which she

> was successfully

> treated w/ acupuncture. She also presented w/

> anxiety and insomnia so

> I encouraged her to consider herbal therapy to which

> she consented.

>

> Past Medical Hx: Remarkable for low back pain, neck

> pain, migraine

> headaches, IBS, asthma, TMJ, tinnitus, duodenal

> ulcer (as child, now

> gastric reflux), anxiety and depression (PTSD due to

> childhood abuse

> which has carried over into early adult

> relationships). She is taking

> Elavil (previously Zoloft, Paxil - 2 yr hx), Buspar,

> Tavis-D, Clartin-

> D, a nasal inhalant and birth control pill. She is

> seeing a counselor

> every other week which seems to be helping her in

> her healing

> process. Her mestrual periods were very irregular

> (long time between)

> prior to taking birth control pills. She describes

> her menses as dark

> and clotty with cramping prior to and during menses.

>

> Current c/o: Decreased appetite (only able to eat

> small amounts of

> chicken, oatmeal and bland things), abdominal

> cramping and diarrhea

> (unlike her previous IBS sx). She is cold all of the

> time (denies

> sweating). Her sleep continue to be poor (she

> previously had def heat

> signs at noc, but not now). She is very fatigued w/

> dizziness and

> tinnitus. Her anxiety has increased with this. She

> has what she

> calls " flashbacks " which result in her behaving as a

> child for

> several minutes until she can work through the

> emotions. She also

> becomes reclusive for several hours at a time.

>

> Her pulse is thin and rapid (approx 110 bpm). Her

> tongue is dark

> (red/purple, seems more purple to me) with an

> unrooted greasy yellow

> coat in the spleen area (medial sides, no coat in

> center or

> elsewhere). Her hands are very cold to the touch,

> feet also cold, but

> not as cold as hands. Her facial complexion is pale

> and lusterless.

>

> In the past, she was clearly yin deficient w/ heat.

> She went home for

> the holidays and returned yesterday with the above

> presentation. I

> believe she has deficiency of Spleen Yang, Liver Qi

> stagnation,

> Heart/Liver blood deficiency, Yin deficiency...

>

> I would like to get a more cohesive Dx of root and

> branch. This was a

> much clearer picture to me before the cold sx became

> prominant. The

> disappearance of the heat symptoms perplexes me as

> the signs (tongue

> and pulse) are still there.

>

> I am unsure of a strategy to treat both the spleen

> yang and disturbed

> shen as most of the basic spleen formulas warn of

> caution in cases of

> deficiency heat.

>

> Your thoughts are appreciated.

>

>

 

 

 

 

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[Guest guest]

, Kimberly McCabe

<kimberlymccabe> wrote:

> Michael,

> From the signs and symptoms you have presented, there

> seems to be some evidence of Liver depression with

> heat, blood stagnation in the lower jiao. Etc...

 

Kimberly:

 

Thanks so much for your response. You obviously put some thought into

it and you helped me take this deeper than I had done previously. I

am working on getting the responses to your additional questions, but

have not been able to reach this patient for the past few days. I

will respond to your questions as soon as I have the answers. Then we

can sort through the possibilities.

 

Michael