Case Study 8

Initial Appointment
Patient age and gender: Female, 61
Chief Complaint and duration: Pain on back (electric drill sensation), radiating
down ulnar nerve of arm
History of chief complaints:
-

Onset: moving the arm

Cause: total shoulder replacement on left shoulder 5 years ago
Quality: sharp pain, 6/10
Relief: heat
Aggravate: movement

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)
Lifestyle:
Occupation: N/A

N/A
N/A
Headache on occiput and forehead; water retention
N/A
Constipation, bloating, gas
Well balanced diet
Room temperature drink
Shortness of breath, chest tightness
N/A
Red
Allergy
Allergy
3-4 hours sleep
Average
Average
Left shoulder, sore / weak lower back
Menopausal

Diet: 3 meals / day, mostly balanced

Exercise: average
Stress: average
Caffeine: 3 cups / day
Drinking: none, smokes 7 cigarettes / day

History of medical Condition:

-

Allergies

Tongue:
-

Purple and short body, red side + tip, thin white coating, papillae, teeth mark

Pulse:
-

72 bpm
Generally slippery and thin

TCM Disease Diagnosis:

Shoulder Pain
TCM Syndrome
Differentiation
Primary
Qi and Blood Stasis on
diagnosis
UB, SI Channel
Secondary
diagnosis
Treatment Method: Done by initial primary
-

SI9 (Bi)
SI10 (Bi)
UB17 (Bi)
UB62 (R)
SI3 (L)
UB40 (Bi)
Hua Tuo Jia Ji: T3-T4
Modality: Tuina was used instead of needles

Treatment Result:
-

Reduced her pain

Treatment Plan:
-

Initial frequency of visit: 2x/wk

Treatment Principle
Move Qi and Blood in UB, SI
Channel

Treatment Recommendations:
-

Exercise more

Case Analysis:
According to the patients intake file, the patient has dull achy pain in her neck,
shoulder, all the way down to her leg is a clear sign of Qi and Blood stagnation.
Upon looking at her tongue, he has purplish short body, thin yellow coating, red
sides and sublingual vein is distended. This is showing sign of blood stasis in MJ,
heat or stagnation in GB / LR. From the pulse, generally they are slippery and thin.
Judging by the pulse, which is generally slippery and thin, shows that there might be
some phlegm and dampness, as well as Qi and Blood deficiency. The Qi and Blood
deficiency may further cause the channels (GB / LR) to have more stagnation since
theres not enough Qi and Blood to fill the vessels. The pain starts to accumulate in
the shoulder and neck area, causing more Qi and Blood stagnation on UB and SI
channels.
Personally, I will try to move his Qi and Blood but will also address the root problem
Dampness invading SP channel. Thus the points I would be using are:
-

SI3 (L) + UB60 (R)

SI9, SI10, SI11
LR3 (R) + LI4 (L)
Yao Tong Xue, Ling Gu, Da Bai to alleviate pain and move Qi and Blood

Follow up:
Last Treatment: Less pain
Chief Complaint: Low back and shoulder pain and tightness
Tongue:
-

Purple body, red tip, wet side, teeth mark, crack in MJ

Pulse:
-

70bpm
Generally deep, weak, wiry

TCM Syndrome Differentiation:

-

Primary: Qi Stagnation on UB Channel

Secondary: LR Qi Stagnation

Treatment Principle:
-

Clear UB channel obstruction

Move LR Qi

Acupuncture Prescription
-

UB40, UB58, UB60

Modality: Tuina on GB32, low back, upper back

Treatment Result:
-

Felt more relaxed

Treatment Plan:
-

Initial frequency of visit: 1x/wk

Treatment Recommendations:
-

N/A

Follow up:
Last Treatment: Gotten better for 2-3 days, and the ST started acting up again
(Bloating)
Chief Complaint: Bloating, indigestion
Tongue:
-

Purple body, red tip, wet side, teeth mark, crack in MJ

Pulse:
-

74bpm
Generally forceful

TCM Syndrome Differentiation:

-

Primary: Qi and Blood stagnation on Tiayang

Secondary:

Treatment Principle:
-

Move Qi and Blood on Tai Yang and Tai Yin

Acupuncture Prescription
-

LI10 (L)
LI4 (L)
SP10 (L)
LR8 (L)
Tuina on REN4, Xi Yan x2, He Ding

Treatment Result:
-

Felt more loose

Treatment Recommendations:
-

Eat warm food