Chief Complaint: burning urination with possible blood
Western Diagnosis: urinary tract infection
Medical History: 54 y.o. female with hx of multiple sclerosis for 26 years, uses wheelchair and cane for ambulation. Weakness in left leg needing assistance to move. Chronic history of urinary tract infections, several a month. Uses a catheter bid for voiding.
Questioning exam: urination: burning when beginning stream, frequency and desire to void is nearly constant. Describes a foul odor, dark yellow color, scanty amount. Reports feeling uncomfortable and “anxious.” no change in bowel movement or appetite. Sleep is restless due to freq urinating and restless leg syndrome. body feels tired and heavy. No h/a, slight pain along right temporal area of head and into jaw. Very thirsty but does not want to drink b/c believes she will have to urinate more.
Pulse exam: t: thin, red dry in middle jiao with dry thin white coat in middle jiao. slv: dark and distended. tender sides with scallops and slight quivering.
p: thready and slightly rapid.
Tongue exam: as above
OM Diagnosis: Blood Lin: acute Damp heat toxin in lower jiao with underlying kidney and liver yin vacuity with poss. yin xu heat.
Treatment Principle: clear heat, transform damp, resolve toxicity, stop bleeding, nourish liver and kidney yin and clear vacuity heat.
Point Prescription: She has been treated for this before throughout her TCM hx. I recommended she call her urologist and pcp for an appointment for urinalysis: and to seek primary care if fever begins.
Herbal Formula: mayway granular made:
liu wei di huang wan 40g
zhi mu 8g
huang bai 10g
pu gong ying 10g
zi hua di ding 10g
zhi zi 10g
e jiao 8g
huang lian 10g
huang qin 10g
wu wei zi 10g
Lifestyle Prescription: maintain water intake, no spicy greasy foods, no breads or white flour
clear bland diet of broths and rice and bitter greens.
Results: within two doses she actually slept through the night which she hasn’t been able to accomplish in months. She did not see any blood in the catheter the next morning. reported a decrease in the urgency and denies pain. still watching it. course of herbs is 10 full days.
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