Case Study 9

Initial Appointment
Patient age and gender: Female, 65
Chief Complaint and duration: Eczema (bacterial infection inside leg)
History of chief complaints:
-

Onset: 15 years ago

Cause: cat bite
Quality: swelling
Relief: Homeopathy
Aggravate: standing
MD gave her antibiotics but she got no result so refused to take them

General Information:

Chills & Fever:

Sweating:
Head & Body:
Urine:
Stool:
Appetite &Taste:
Thirst & Drink:
Chest & Abdomen:
Ears:
Eyes:
Nose:
Throat:
Sleep:
Emotions:
Energy:
Pain:
Female condition:
(age of menarche,
date of last period,
duration (days of
flow), intervals,
amount, clots, colour,
contraception,
menopause, PMS)

Cold legs and feet

N/A
Intense left eyebrow sharp pain (5min, every couple of
months); itchy
Often, light colored, urgent small amount
N/A
3-4 meals per day
Feels thirsty but restricts her own intake
Tight, pressure in the HT
Tired, itchy, sore
Tired, itchy, sore
N/A
N/A
Easily fall asleep, wakes up to urinate 1-2x / night; 7 hrs,
good quality sleep, rested
Low
Average
Low back and neck
Menopausal

Lifestyle:
Occupation: works in a bar at night, 20hrs/wk
Diet: 3-4 meals / day, mostly cold and raw food, snacks a lot on fruits
Exercise: gardening
Stress: High
Caffeine: N/A
Drinking: N/A

History of medical Condition:

-

HT Disease, High Blood Pressure, Skin and Thyroid Disease

Tongue:
-

Purple body, red tip, pale tongue; thin white coating in LJ, teeth mark

Pulse:
-

78 bpm
Generally deep and irregular
Wiry SP
Hesitant HT

TCM Disease Diagnosis: Eczema

Primary
diagnosis
Secondary
diagnosis

TCM Syndrome
Differentiation
Qi and Blood Deficiency
KI Yin Deficiency

Treatment Method: Done by initial primary

-

ST36 (L)
REN17
SP6 (L)
KI7 (L)
YinTang
Modality: tuina
Ear seed: Ear Shenmen x2

Treatment Result:
-

Relaxed, fell asleep during treatment

Treatment Principle
Tonify QI
Nourish Blood
Nourish KI Yin
Calm the mind

Treatment Plan:
-

Initial frequency of visit: 1x/wk

Treatment Recommendations:
-

Walk more, keep body warm

Case Analysis:
To properly analyze this case, we need to take a look at her medical history. She
mentioned that this was caused by a cat bite 15 years ago. The eczema has not
gone away even after 15 years, which means theres toxic lying deep in her tissue
(leg). Judging by her pulse, she has a bit of stagnation accumulation in her SP
channel (wiry pulse) and KI Yang Deficiency (deep weak pulse). As we assess the
tongue, there is some heat in the HT region, and the pale tongue supports Yang
Deficiency. When we further delve into her diet, which is mostly cold and raw food
that tend to injure Yang, further backup the theory of Yang Deficiency. The irregular
pulse also represents cold obstruction for Qi and Blood deficiency, which may also
lead to Yang deficiency.
Since her main complaint is to help with her eczema, we need to get rid of the toxic
heat, and her being Yang deficient means her Qi and Blood wont be moving as
quickly as it should to get rid of the toxin. So my choice of points:
-

Bleed LR1, SP1 and ST45

Tonify KI7, SP6, SP10 to further move the blood
LI4 to clear heat

Follow up:
Last Treatment: Less itchy, Gua Sha worked
Chief Complaint: Plantars Warts (R) ball of foot, eczema
Tongue:
-

Purple body, red tip, orange side, papillae, thin yellow coating (inside), white
coating (outside), thick at root, wet
Distended sublingual

Pulse:
-

56bpm
Generally irregular, wiry, deep
Deep and hidden KI Yang & Yin

TCM Syndrome Differentiation:

-

Primary: Toxic heat

Secondary: KI Yang & Yin Def

Treatment Principle:
-

Clear Toxic Heat

Tonify KI Yang & Yin

Acupuncture Prescription
-

SP6 (Bi)
SP10 (Bi)
GB34 (Bi)
UB23 (Bi)
UB40 (Bi)
LI11 (Bi)

Treatment Result:
-

Relieved itch

Treatment Plan:
-

Initial frequency of visit: 1x/wk

Treatment Recommendations:
-

Bleed UB40 in next treatment

Follow up:
Last Treatment: N/A
Chief Complaint: 2-3 wks of diarrhea with undigested food and congestion
Tongue:
-

Wet, red side, tip, pale body, thin yellow coating LJ, papillae
Distended sublingual vein

Pulse:
-

76bpm
Generally weak and deep and wiry
Slippery SP

TCM Syndrome Differentiation:

-

Primary: Cold invading ST

Secondary: SP Qi Def

Treatment Principle:
-

Warm ST
Dispel Cold
Tonify SP Qi

Acupuncture Prescription
-

ST25 (Bi)
ST36 (L)
ST37 (R)
REN4
REN12
SP6 (R)
LI4 (L)

Treatment Result:
-

Intestinal moving sound was heard

Treatment Recommendations:
-

Eat warm food