Chief Complaint: allergies
Medical History: Patient is a 30 year old male, sedentary lifestyle,diet includes much dairy and spicy foods, no excessive smoking or drinking.
Questioning exam: Patient reported being under stress and feeling very congested with yellow phlegm, a lot of sneezing, itchy watery eyes, fatigue, and a sensation of heaviness in his head. Condition was worsened by the drafty environment he worked in.
Pulse exam: Pulse was slippery and somewhat weak
Tongue exam: Tongue was puffy, had a purple middle and a red tip.
Eyes were red.
OM Diagnosis: The patient had a mixture of qi stagnation, damp heat and phlegm accumulation in the upper burner as well as spleen qi deficiency. Qi stagnation was from the stress and damp obstruction. The indicators of heat were yellow phlegm, red eyes, and red tip of the tongue. Also there was some spleen qi deficiency which led to the damp accumulation.
Treatment Principle: Clear damp heat and phlegm, tonify the spleen, and move qi.
Point Prescription: Acupuncture points were shishengong, du 23, yin tang, bitong, si 18, ren 17. On the left side, li 4, sj 5, li 11, spleen 9, spleen 6, liver 3. On the right side, lung 7, lung 10, heart 7, st 36, st 40, gb 34.
Herbal Formula: Patent formula from Golden Flower of Jade Screen and Xanthium (Yu Ping Feng Jia Cang Er San).2 3Xdaily
Lifestyle Prescription: Suggested he eat less dairy and spicy foods as well as staying away from very cold foods. Encouraged him to start a mild workout program and progress from there. Told him to wear a scarf when the weather was windy or cold as well as at the office.
Results: Results were good. He reports no bad bouts with allergies in a year.
Synopsis: Patient was treated over a period of 2 months. He began with 2 treatments per week for the first 3 weeks; then cut down to once a week. Following the 2 month period, he came in twice during the next 3 months but continued to take the herbs regularly. He complied with the other suggestions but did not work out as regularly as advised. Results were very good.
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