Submitted By: dcasinelli
African American Female
44 yrs old.
Main Complaint: daily severe left side headaches from trauma, ‘92.
Secondary Complaint: plantar fascitis
Other: benign thyroid tumors.
Signs and Symptoms
Shen: white, damp/oily, lively, eyes bulge
Tongue: dry, sl. purple,
Pulse: LV and KD Yin weak.
Fire; pungent smell w/headaches, excess spinal fluid (TW), hyperthyroid, difficulty falling asleep, palpitations
Earth; joint pain and bronchitis worse in damp weather, weight gain, bloating, fatigue, acne around mouth, chin; sinusitis, bleeds and bruises easily, halitosis
Metal; bronchitis, sinusitis
Water;excess spinal fluid and spinal shunt to drain it, more h/a since pregnancy, heel plantar fascsitis, hx kidney stones, menarche age 9, low back pain.
Wood;neck pain, hernia, difficult mense
H/C: often hot.
Hospitalization; fused cervical vertebrae, 2 shunts to drain spinal fluid, 3 uneventful births, thyroid removed after 4 month of treatment.
I’ve been treating this patient as part of a study of Gulf War Illness, though I doubt her imbalance is a result of exposure to heat toxins or bugs. Her headaches are unusual in that they are often accompanied by her sensing a strong odor of amonunia. The western dx is excess spinal fluid (!) for which they installed two shunts that must be monitored and drained. Most of the time the headaches are left sided/occipital. They exasperate/are worsened by neck tension. She is slightly overweight. Many of the Fire symptoms improved after her thyroid was removed.
Diagnosis: local stagnation, KD Yin and Yang Deficient, SP deficient, damp, LV Qi Stagnation.
16 treatments, short break after 12. None of my treatment strategies/point choices have been unusual. Mostly I use LI4 & Kd3 with the ear point for the occiput, which is very tender upon palpation. Sometimes I’ll do local needling/add points for neck pain and LV Qi Stagnation or Damp, Deficient SP. Occasionally I’ve cupped her upper back.
Duration and Outcomes
The patient makes steady progress while in treatment, however as soon as she discontinues treatment, her symptoms return–and that’s what I’d like help with!