Western Diagnosis: Reynaud’s Phenomenon
Medical History: 56 y.o. male with h/o mild HTN, BPH. Very active, a runner, healthy diet with vigorous exercise routine. On meds for HTN & BPH.
Questioning exam: Presented with c/o cold hands and feet, worse in cold weather. Hands appeared purple at distal portion pink on dorsal palms and white on proximal palms. Hands were very cold to touch.
Pulse exam: Hands & feet were otherwise soft and supple, sometimes moist and clammy. Pulses were normal except for SP/LV pulses which varied between slow to soggy for the spleen and wiry for the liver
Tongue exam: Tongue was moist and pink with a slightly thicker white to occasionally yellow coat at the base.
OM Diagnosis: Spleen qi deficiency with damp/phlegm, Lv qi stagnation.
Treatment Principle: Tonify the spleen, dispel damp, transform phlegm, freecourse liver qi
Point Prescription: 4 gates, ba xie, ba feng, sp 6, st 36, st 40 li 10 or li 11 (ashi)
ba xie and ba feng with moxa cones X3, alternating with e-stim from li 10 or li11 to ba xie & st 40 to bafeng
Herbal Formula: pt did not want to take herbs
Lifestyle Prescription: reviewed dietary habits and made some minor changes
Results: after six months of treatment, the pt’s hands were no longer purple and cyanotic looking but were pink overall, still slightly cold to touch but with noticeable improvements in temperature. the pt’s blood pressure had also improved from initial bp’s of 160/100 to 120-130/70-80. Pt’s also stated his cardiologist was impressed and did not wish to see him for 6 months, unless he felt the need to be seen.
Synopsis: By focusing on the overall circulation issues and making small dietary changes, this patient manifested significant improvement of his initial c/o cold hand & feet.