Chief Complaint: Ear pain and head ache
Western Diagnosis: Ear infection and fluid accumulation
Medical History: Lower back pain(dull), inability to get pregnant for 4 months, 2 miscariages in the past.
Questioning exam: Appetite is well, sleep is well, urination bowel all normal. No cold hands feet, very seldom dizzy especially after squatting.
Pulse exam: pulse weak yet somewhat tense in deep palpitation.
Tongue exam: Tongue coat normal, material little pale.
OM Diagnosis: Long standing kidney Yang deficiency, GB liver little upset.
Treatment Principle: strengthen KD Yang and clear Liver/GB
Herbal Formula: Ren Shen by itself.
Chai Hu, Gou Teng, Bai shu, Da Zao.
Little dose of Lu Gen to keep heat in check and moisture in place used once a day for 14 days