Chief Complaint: spontaneous sweating, nervousness
Western Diagnosis: anxiety
Medical History: recent weight loss of 150 lbs, recent dramatic change in lifestyle from unhealthy, greasy, sweet and alcohol diet to a healthy one (hence the weight loss) many traumatic life events; deaths of close loved ones, divorce.
Questioning exam: unstable emotions
mental restlessness worse at night
low energy
sweating on palms and legs, worse with anxiety
lots of dreams
persistent low grade nausea
occasionally morning bowel movement triggers vomiting and abdominal cramps
constant back pain, tightness; better with movement
Pulse exam: skin very damp
clear sweat
pulse sunken and weak in especially in the lung area, unsmooth
Tongue exam: light purple, pale body color, thick, greasy, yellowish coating
OM Diagnosis: lung and stomach qi deficiency, phlegm heat, qi stagnation
Treatment Principle: remove obstructions, disperse fluids regulate stomach qi, tonify qi, calm spirit
Point Prescription: 1st treatment: aggressive energy
2nd treatment: internal dragons
3rd treatment: st36, lu7, pc6, kd9, kd26, kd7, li4, ht6 all contralateral except kd26, lu7
Herbal Formula: gan mai da zao tang with wen dan tang
Lifestyle Prescription: replacement of coffee with herbal tea
Results: back pain gone for several days after AE, felt a tangible weight lifted off….
2nd treatment not as noticeable effect but felt calmer the whole week
3rd treatment felt very electrical… went home and cried for aver an hour
Synopsis: continuation of moving qi, disperse fluids, dissolve phlegm…. tonify lung qi
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