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I would appreciate some feedback regarding this patient. Specifically from

the herbal department

History :

 

1. 46 yo. Female

2. cc (chief complaint) Digestive sensitivities

3. allergic to all foods to some degree except raw almonds

4. Dx with parasite(algae name unknown) 1999 and damaged small intestine

5. Antibtiotic 7 days = cramping, diarrhea, vomiting stopppd antibiotic

6. Elimination diet for 1 and a half years

7. Things were starting to get better until 8 months ago when it just went

downhill

8. Took enzyme supplement = made her totally sick

9. Other Findings :

10. Dx with endometriosis in 1979. Had child in 80, 81.

11. 1987,88 endometriosis resurface=headaches, leg cramps, nausea, left

ovary like a grapefruit

12. prescribed birth control pills…but she only took them for a short time

13. Took Chinese herbal med which " totally made her better "

14. Started Synthroid 5.5 years ago

15. History of sinus infections leading to bronchitis, pneumonia, then

pleurisy. For years as a child she would get pneumonia twice a year

16. Long history of child abuse which consisted of getting hit in the

stomach over a period of years

Findings:

1. Temp : cold to the core but synthroid has helped her a little

2. Partner tells her she sweats at night

3. Dry eyes, dry nails, dry skin

4. Clenches teeth : cracked tooth from clenching at night

5. Sciatic neuritis that is deep in the pelvis an shifts from left to right

hamstring

6. Dr. tell her she has high iron count in blood but on two occasions this

year she gave blood and could not fill the bag then subsequently could not

get off the table and was freezing cold

7. Recently getting PMS which she never had

8. Vision worse at night

9. GI : no diarrhea today but watery if she has it as an allergic reaction

10. DOES NOT LIKE PRESSURE

11. Diet : consists of mostly cold foods and nutrient drinks

12. If she does not exercise she is totally wired and must move around.

13. Approx 5’2 120 lbs

 

Tongue : dry no coat, with red tip

Sublingual distension – WNL (within normal limits)

Pulse : I am currently studying the Shen/Hammer system: Globally her pulse

feels tight to wiry which tells me she is on the continuum of Yin deficiency

Rate : 60 bpm

Treatment : 4 gates, st 36, sp 6, moxa ren 12

she commented that when she had treatment before it felt as though she was

floating. This time it felt much more grounding as though she was held to

the table. I took this as a good sign.

 

My question is about prioritizing her syndrome herbally? I started her on a

spleen tonic to be taken with fresh grated ginger which she remembered she

had been given before successfully. However, what about the yin def, blood

def, and stagnation as prioroties? My other hit on formulas would be to

nourish stomach yin or something on the continuum of Si Ni San to move

stagnation

 

Any thoughts, suggestions, ideas, criticisms are appreciated.

Thank you for your time in responding

 

Kelly

 

 

_______________

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Kelly,

 

Sounds like you got your hands full! Has your patient been for any

psychotherapy? Judging by the Hx, sounds like some serious emotional

issues at hand need to be addressed. You may want to consider this in

your herbal rx.

 

Fernando

 

, " Kelly Welch " <kdwelch25@h...> wrote:

>

> I would appreciate some feedback regarding this patient.

Specifically from

> the herbal department

> History :

>

> 1. 46 yo. Female

> 2. cc (chief complaint) Digestive sensitivities

> 3. allergic to all foods to some degree except raw almonds

> 4. Dx with parasite(algae name unknown) 1999 and damaged small

intestine

> 5. Antibtiotic 7 days = cramping, diarrhea, vomiting stopppd

antibiotic

> 6. Elimination diet for 1 and a half years

> 7. Things were starting to get better until 8 months ago when it

just went

> downhill

> 8. Took enzyme supplement = made her totally sick

> 9. Other Findings :

> 10. Dx with endometriosis in 1979. Had child in 80, 81.

> 11. 1987,88 endometriosis resurface=headaches, leg cramps, nausea,

left

> ovary like a grapefruit

> 12. prescribed birth control pills…but she only took them for a

short time

> 13. Took Chinese herbal med which " totally made her better "

> 14. Started Synthroid 5.5 years ago

> 15. History of sinus infections leading to bronchitis, pneumonia,

then

> pleurisy. For years as a child she would get pneumonia twice a year

> 16. Long history of child abuse which consisted of getting hit in

the

> stomach over a period of years

> Findings:

> 1. Temp : cold to the core but synthroid has helped her a little

> 2. Partner tells her she sweats at night

> 3. Dry eyes, dry nails, dry skin

> 4. Clenches teeth : cracked tooth from clenching at night

> 5. Sciatic neuritis that is deep in the pelvis an shifts from left

to right

> hamstring

> 6. Dr. tell her she has high iron count in blood but on two

occasions this

> year she gave blood and could not fill the bag then subsequently

could not

> get off the table and was freezing cold

> 7. Recently getting PMS which she never had

> 8. Vision worse at night

> 9. GI : no diarrhea today but watery if she has it as an allergic

reaction

> 10. DOES NOT LIKE PRESSURE

> 11. Diet : consists of mostly cold foods and nutrient drinks

> 12. If she does not exercise she is totally wired and must move

around.

> 13. Approx 5'2 120 lbs

>

> Tongue : dry no coat, with red tip

> Sublingual distension – WNL (within normal limits)

> Pulse : I am currently studying the Shen/Hammer system: Globally her

pulse

> feels tight to wiry which tells me she is on the continuum of Yin

deficiency

> Rate : 60 bpm

> Treatment : 4 gates, st 36, sp 6, moxa ren 12

> she commented that when she had treatment before it felt as though

she was

> floating. This time it felt much more grounding as though she was

held to

> the table. I took this as a good sign.

>

> My question is about prioritizing her syndrome herbally? I started

her on a

> spleen tonic to be taken with fresh grated ginger which she

remembered she

> had been given before successfully. However, what about the yin def,

blood

> def, and stagnation as prioroties? My other hit on formulas would be

to

> nourish stomach yin or something on the continuum of Si Ni San to

move

> stagnation

>

> Any thoughts, suggestions, ideas, criticisms are appreciated.

> Thank you for your time in responding

>

> Kelly

>

>

> _______________

> MSN Photos is the easiest way to share and print your photos:

> http://photos.msn.com/support/worldwide.aspx

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Share on other sites

  • 1 month later...

My question is about prioritizing her syndrome herbally? I started her on a

spleen tonic to be taken with fresh grated ginger which she remembered she

had been given before successfully. However, what about the yin def, blood

def, and stagnation as prioroties? My other hit on formulas would be to

nourish stomach yin or something on the continuum of Si Ni San to move

stagnation

 

Any thoughts, suggestions, ideas, criticisms are appreciated.

Thank you for your time in responding

 

Kelly

 

>>>>Kelly was just wandering what happened with this case

Alon

-

" Kelly Welch " <kdwelch25

 

Friday, December 14, 2001 3:48 AM

case study inquiry

 

 

 

I would appreciate some feedback regarding this patient. Specifically from

the herbal department

History :

 

1. 46 yo. Female

2. cc (chief complaint) Digestive sensitivities

3. allergic to all foods to some degree except raw almonds

4. Dx with parasite(algae name unknown) 1999 and damaged small intestine

5. Antibtiotic 7 days = cramping, diarrhea, vomiting stopppd antibiotic

6. Elimination diet for 1 and a half years

7. Things were starting to get better until 8 months ago when it just went

downhill

8. Took enzyme supplement = made her totally sick

9. Other Findings :

10. Dx with endometriosis in 1979. Had child in 80, 81.

11. 1987,88 endometriosis resurface=headaches, leg cramps, nausea, left

ovary like a grapefruit

12. prescribed birth control pills.but she only took them for a short time

13. Took Chinese herbal med which " totally made her better "

14. Started Synthroid 5.5 years ago

15. History of sinus infections leading to bronchitis, pneumonia, then

pleurisy. For years as a child she would get pneumonia twice a year

16. Long history of child abuse which consisted of getting hit in the

stomach over a period of years

Findings:

1. Temp : cold to the core but synthroid has helped her a little

2. Partner tells her she sweats at night

3. Dry eyes, dry nails, dry skin

4. Clenches teeth : cracked tooth from clenching at night

5. Sciatic neuritis that is deep in the pelvis an shifts from left to right

hamstring

6. Dr. tell her she has high iron count in blood but on two occasions this

year she gave blood and could not fill the bag then subsequently could not

get off the table and was freezing cold

7. Recently getting PMS which she never had

8. Vision worse at night

9. GI : no diarrhea today but watery if she has it as an allergic reaction

10. DOES NOT LIKE PRESSURE

11. Diet : consists of mostly cold foods and nutrient drinks

12. If she does not exercise she is totally wired and must move around.

13. Approx 5'2 120 lbs

 

Tongue : dry no coat, with red tip

Sublingual distension - WNL (within normal limits)

Pulse : I am currently studying the Shen/Hammer system: Globally her pulse

feels tight to wiry which tells me she is on the continuum of Yin deficiency

Rate : 60 bpm

Treatment : 4 gates, st 36, sp 6, moxa ren 12

she commented that when she had treatment before it felt as though she was

floating. This time it felt much more grounding as though she was held to

the table. I took this as a good sign.

 

My question is about prioritizing her syndrome herbally? I started her on a

spleen tonic to be taken with fresh grated ginger which she remembered she

had been given before successfully. However, what about the yin def, blood

def, and stagnation as prioroties? My other hit on formulas would be to

nourish stomach yin or something on the continuum of Si Ni San to move

stagnation

 

Any thoughts, suggestions, ideas, criticisms are appreciated.

Thank you for your time in responding

 

Kelly

 

 

_______________

MSN Photos is the easiest way to share and print your photos:

http://photos.msn.com/support/worldwide.aspx

 

 

 

Chinese Herbal Medicine, a voluntary organization of licensed healthcare

practitioners, matriculated students and postgraduate academics specializing

in Chinese Herbal Medicine, provides a variety of professional services,

including board approved online continuing education.

 

 

 

 

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