Chief Complaint: Numbness and tingling in lower extremities
Western Diagnosis: Peripheral Neuropathy diagnosed in 1996
Medical History: Illnesses and Operations:
1. Bilateral inguinal hernia operation in 1981.
2. Had tumor removed behind right eye caused by a basal carcinoma in 1987. Had 4 operations following initial surgery for cosmetic reasons.
3. Reports having other basal cell carcinomas removed included one while I saw him in January.
4. Had Ulcerated Colitis in 1991 which was successfully treated.
General Heath: Good.
Tobacco: Smoked since 25, presently smokes 2 packs daily since quitting alcohol.
Coffee: Drinks 4 cups daily.
Exercise: One and a half hours a day.
Described Neuropathy as a feeling of sand is his shoes and semi-numbness which is present 100% of the time. Also has associative symptoms of dizziness, lack of balance when eyes closed, and not knowing where feet are in space. Sensation covers half way down lower legs to entire feet. Symptoms are better in morning and get worse as day progresses. Started 2 years ago with a sudden onset. Described having a fall when drunk and hitting head on fireplace, which knocked him unconscious. Symptoms started 2 to 3 days after accident. Has a history of alcoholism for thirty years which now he is in recovery and has not drank for 18 months. Has been tested negative for diabetes.
Arthritis gets worse in damp weather, has a feeling of swelling and warmth. Gets worse with physical exercise, like golf. Has been present for 10 years and has been getting progressively worse with time.
Temperature: Reports normal.
Perspiration: Reports normal.
Head: Gets low grade headaches over entire head on average of 4 times a week. Has disorientation, dizziness and shaky when eyes closed.
Nose, Sinuses: Has chronic allergies from change in seasons which creates runny nose.
Eyes: Reading glasses for 10 years.
Ears: Some ringing. Has high and low hearing loss.
Sleep: Requires 6 hours a night. Feels rested.
Skin: Very dry over entire body. Has phlegm nodules on legs. Skin cancer mentioned above.
Body Pain: Chronic low back pain.
Appetite: Reports good, craving sweets
Urination: Reports normal.
Stool: On constipation side.
Thirst: Reports normal.
Energy Level: On the manic side, is always going, from moment he awakes to he goes to sleep.
Pulse exam: Pulse: Slippery, deep, and short quality, deficient in Lung, Heart, and Kidney positions.
Abdominal Findings: Deficient in Spleen and Kidney areas, tight in liver area.
Meridian Palpation and Examination: He has phlegm nodules running down lower leg covering parts of stomach, and gall bladder channels. Has one over St. 40.
Tongue exam: Tongue: Tender sides, body is dusky and pale, quivering, coat is greasy over entire tongue.
OM Diagnosis: Stagnation of Phlegm in channels of legs with underlying Liver and Kidney Yin Xu, and Liver Xue Xu.
Treatment Principle: Expel phlegm, move qi and blood in channels, supplement kidney and liver yin, supplement liver blood.
Point Prescription: Sp. 9 Resolve dampness and phlegm.
St. 40 Resolve and move phlegm in channels.
St. 36 Supplement and frees Qi and blood in channels.
Foot and Hand San Char(14 points) Relieves numbness and moves channels.
LI 4 Frees channels and network vessels.
Kid. 3 Supplements Kidney yin.
Ren 9 Disinhibits damp.
Yintang Calm Shen.
Ear: Shenmen, kidney, liver.
Herbal Formula: Du Huo Ji Sheng Tang-
Du Huo 9g.
Xi Xin 6g.
Fang Feng 6g.
Qin Jiao 6g.
Sang Ji Sheng 6g.
Du Zhong 6g.
Niu Xi 6g.
Rou Gui 6g.
Dang Gui 6g.
Chuan Xiong 6g.
Sheng Di Huang 6g.
Bai Shao 6g.
Ren Shen 6g.
Fu Ling 6g
Zhi Gan Cao 6g.
Er Chen Tang-
Ban Xia 15g.
Chen Pi 15g.
Lifestyle Prescription: No dairy products
Rise dosage of vitamin B12
Results: The first 2 months of treatment the Neuropathy stayed the same and his secondary complaint of arthritis improved. In the remaining 3 months of treatment his numb sensation is now only on his feet and toes. He reports that his orientation and balance is better and over all reports he feels 50% better since treatment.
Synopsis: This is a slow moving condition. It was a learning experience to see what alcohol could do to someone over a long period of time. Also he is a very strongly a man. He was a football coach, was in the Marines, played football, got in a lot of fights. I on the other hand am a passivist, don’t like sports, would never join the military. It is a learning experience of how to have my issues yet still be there with him.