What follows is a detailed case record of an M.A, female, 46 who presented with help heel pain and how we helped her with our acupuncture and herbal medicine.
The First Consultation 07/03/2012
Symptoms and Signs:
- Right heel spur causes pain for 4 months. Aggravated for 2 months.
- Sleep is fine
- Stressed because of divorce process
- Energy is not enough
- Right shoulder has been sore for 1 year since she did lots of painting last year.
- Weight gain
- Tongue: light red with thin white coat
- Pulse: Wiry and a little bit deep
TCM Differential Diagnosis: Deficiency of Kidney Yin, Liver Qi stagnation
Treatment: Nourish the Kidney Yin. Soothing the Liver Qi flow
Acupuncture: Zhong Wan, Tai Xi, Tai Chong, Zu San Li, San Yin Jiao, Yin Tang, Shen Meng
Herbal Medicine: Modified Liu Wei Di Huang Wan, Shu Di Huang 24g, Shan Yao 24g, Shan Zhu Yu 15g, Dan Pi12g, Fu Ling 15g, Ze Xie 15g, Dang Shen 18g, Chai Hu 6g, Bai Shao 15g, Dan Gui12, Zi Ke12, Gan Cao 6g, Bai Zhu12g. Herbal international granules form. 8grams, twice per day. with Salompas patch twice per day
The Second Consultation 14/03/12
Symptoms and Signs:
- Right heel pain got better for 3 days and then worse again
- Sleep is fine
- Stressed a little bit
- Energy is better
- Right shoulder pain is better
- Tongue: light red with thin white coat
- Pulse: Wiry and a little bit deep
TCM Differential Diagnosis: Deficiency of Kidney Yin, Liver Qi stagnation
Treatment: Nourish the Kidney Yin. Soothing the Liver Qi flow
Acupuncture: Zhong Wan, Tai Xi, Tai Chong, Zu San Li, San Yin Jiao, Yin Tang, Shen Meng
Herbal Medicine: Modified Liu Wei Di Huang Wan, Shu Di Huang 24g, Shan Yao 24g, Shan Zhu Yu 15g, Dan Pi12g, Fu Ling 15g, Ze Xie 15g, Dang Shen 18g, Chai Hu 6g, Bai Shao 15g, Dan Gui12, Zi Ke12, Gan Cao 6g, Bai Zhu12g. Herbal international granules form. 8grams, twice per day. with Salompas patch twice per day
The Third Consultation 22/03/12
Symptoms and Signs:
- Right heel pain is much better
- Sleep is fine
- Stressed a little bit
- Energy is better
- Right shoulder pain is better
- Tongue: light red with thin white coat
- Pulse: Wiry and a little bit deep
TCM Differential Diagnosis: Deficiency of Kidney Yin, Liver Qi stagnation
Treatment: Nourish the Kidney Yin. Soothing the Liver Qi flow
Acupuncture: Zhong Wan, Tai Xi, Tai Chong, Zu San Li, San Yin Jiao, Yin Tang, Shen Meng
Herbal Medicine: Modified Liu Wei Di Huang Wan, Shu Di Huang 24g, Shan Yao 24g, Shan Zhu Yu 15g, Dan Pi12g, Fu Ling 15g, Ze Xie 15g, Dang Shen 18g, Chai Hu 6g, Bai Shao 15g, Dan Gui12, Zi Ke12, Gan Cao 6g, Bai Zhu12g. Herbal international granules form. 8grams, twice per day. with Salompas patch twice per day
The Fourth Consultation 28/3/12
Symptoms and Signs:
- Right heel pain is much better
- Sleep is fine
- Stressed is better
- Energy is much better
- Right shoulder pain is fine
- Tongue: light red with thin white coat
- Pulse: not as wiry and deep
TCM Differential Diagnosis: Deficiency of Kidney Yin, Liver Qi stagnation
Treatment: Nourish the Kidney Yin. Soothing the Liver Qi flow
Acupuncture: Zhong Wan, Tai Xi, Tai Chong, Zu San Li, San Yin Jiao, Yin Tang, Shen Meng
Herbal Medicine: Keep taking Sunherbal’s Liu Wei Di Huang Wan, 12 pills, twice per day for another 2 weeks.