Simon Huang

Case Study 2
Initial Appointment
Patient age and gender: Male, 44
Chief Complaint and duration: Fatigue, sore feet and low back
History of chief complaints:
-

Onset: 6 months, weight gain

Cause: Lack of exercise
Quality: Dull, damp, heavy pain in back, all year round
Location: Back = centre of spine, L2-L3 (DU-4), Feet = top of feet,
lateral (Dorsal)
Relief: Back = Pressure, rest, winter (really cold), Feet = Pressure,
Fatigue = Sleep, coffee
Aggravate: End of day / long sitting, summer, Back = , Fatigue = Meat
or carbs
No medical test

General Information:
Chills & Fever:
Sweating:
Head & Body:
Urine:
Stool:
Appetite &Taste:
Thirst & Drink:
Chest & Abdomen:
Ears:
Eyes:
Nose:
Throat:
Sleep:
Emotions:
Energy:
Pain:
Female condition:
(age of menarche,
date of last period,
duration (days of
flow), intervals,
amount, clots, colour,
contraception,
menopause, PMS)

Feels hot, removes covers during sleep, open windows

while driving
Night sweat
Throbbing headache (occipital + forehead) 8/10; every
other day; aggravated by weather; Legs (edema?)
Wakes up 1-2x / night
1x / day, well formed
Mostly fast food, post meal fatigue (meat and carbs)
N/A
Ear ache with headache (left ear)
Blurry vision at the end of the day (takes longer to focus)
Congested, frequent sneezing
6 hours, terrible, toss & turn, snores, night sweat
Even
High (adrenaline)
Sore feet and low back pain
N/A

Simon Huang

Lifestyle:
Occupation: self-employed
Diet: fast food mostly
Exercise: daily walking; work = construction / active
Stress: high
Caffeine: 2 cups / day
Drinking: N/A
History of medical Condition:
-

N/A

Tongue:
-

Scallop, thin wet white coat, pale body, little quiver

Pulse:
-

80 bpm
Generally strong, slippery, wiry
Rooted / Deep (KI)

TCM Disease Diagnosis:

Primary
diagnosis
Secondary
diagnosis

TCM Syndrome
Differentiation
Ki Yin Def
SP Qi Def w/ Damp

Treatment Method: Done by initial primary

-

SP6 (Bi)
KI6 (Bi)
DU3
SI3 (L) + UB60 (R)
UB20 (Bi)
Tuina on the back

Treatment Result:
-

Feet: milder pain

Body: 4-5/10 compared to 7-8/10
Slept during treatment

Treatment Principle
Tonify KI
Nourish Yin
Strengthen low back
Stop Pain
Tonify SP
Drain Damp

Simon Huang

Treatment Plan:
Initial frequency of visit: 4x/wk for 6 wks
Treatment Recommendations:
-

Healthier food compared to fast food

Legs up on the wall (5min)
Insomnia cure (yoga)
Venous return
Suggested to do SJ6 and Low pt

Case Analysis:
Judging by the initial intake, the patient is showing signs of clear KI
deficiency. The lower back pain, feet pain, I remember more to his medial
ankles. The dull, heavy painful sensation in DU4 area is also a clear
indication of KI deficiency. He has also been sitting for long time, which may
have injured KI. The fact that hes also working actively in construction world,
often will carry heavy things and walk with it. Thus this will also put
excessive weight on his ankle and feet, may cause Qi and Blood obstruction
to the channels (KI, SP, LR, UB, ST, GB). Being KI deficient, the patient is also
suffering ear ache (KI channel opens up to the ears). Lastly, to find out
whether he is more Ki Yin or KI Yang deficient, we need to take a look at
different aspect. In the first glance, the patient has low back pain, pale, wet
tongue, deep-weak pulse, urination at night, edema of legs. These symptoms
are clear indication of KI Yang deficiency. However, he also suffers from night
sweating, which can be a manifestation of KI Yin deficiency. KI deficiency is
usually a combination of both Ki Yin and KI Yang, but in his case, its more
prominent for KI Yang deficient due to his pulse. With KI Yin deficiency, pulse
is usually floating and empty, however, he is showing deep and weak pulse,
which represents more of KI Yang deficiency.
He does show a secondary pattern of SP Qi Deficient caused by Damp
accumulation, since hes eating mostly fast food (meat and carbs). The fact
that he has his own construction company, hes often thinking about the next
move for the company, thus in TCM term, its over thinking or pensiveness.
Combining with irregular diet, pensiveness may lead to SP Qi Deficiency. To
back up this assumption, we can see that his pulse is generally Slippery,
which is indicative for Dampness pattern as the result of SP Qi deficiency.
The primary diagnosis in this patient in my opinion will be KI Yang Deficient,
and the treatment principle will be tonify and warm KI Yang and strengthen
Ming Men Fire. The acupuncture points Id choose in this patient will be a
face down treatment with:
-

DU4, UB23, UB52 (needle + moxa) to tonify KI and strengthen Ming

Men Fire

Simon Huang

KI3, KI7 to tonify KI Yang

SI3 + UB60 to open DU channel

The secondary diagnosis in this patient is SP Qi Deficient with Damp, and I

agree with the initial practitioners choice of points.
Follow up:
Chief Complaint: Neck turning sideway trouble
Pulse:
-

84bpm
Generally wiry
Deep KI Yang, Deep & Weak KI Yin
Slippery SP
HT is deep and strong

TCM Syndrome Differentiation:

-

Primary: Qi Stagnation on ShaoYang Channel

Secondary: Qi Def

Treatment Principle:
-

Move Qi on ShaoYang Channel

Tonify Qi

Acupuncture Prescription
-

GB41 (R)
DU20
SI3 (L)
UB62 (R)
Luo Zhen (Bi)

Treatment Result:
-

Neck turns better with less pain

Treatment Plan:
Initial frequency of visit: 1x/wk
Treatment Recommendations:
-

Soak feet with hot water and Epsom salt

Follow up:
Last Treatment: Neck strain didnt come back

Simon Huang

Chief Complaint: Tension on spine, neck; left shoulder cranky; right ankle
pain
Pulse:
-

94bpm
Generally forceful
Deep KI Yin and Yang
Wiry LR
Deep LU and HT

TCM Syndrome Differentiation:

-

Primary: Qi Stagnation on TaiYang Channel

Secondary: LR Blood Def

Treatment Principle:
-

Move Qi on TaiYang Channel

Nourish LR Blood

Acupuncture Prescription
-

LI10
LI4
UB62
SI3 (R)
LR3
SI4 (L)

Treatment Result:
-

Neck strain is better

Treatment Recommendations:
-

Soak feet in warm water with Epson salt and ginger, drink less alcohol