Case History: A Year With Acupuncture 40 y/o Male, 30+ Year History of Autoimmune Disorder

A Year With Acupuncture: Case history, 40 y/o male, 30+ year history of autoimmune disorder.

Sx’s: Diverticulitis, rheumatism with multiple joint pain, gout, anemia, fatigue, psoriasis, acne, rhinitis, migraines, fatty liver, stomach pain, night sweating, frequent sweat, dry mouth, burning tongue, mouth sores, metallic taste in mouth, swollen neck glands, eye redness and itching, diarrhea, irritability, easily stressed, propensity to anger.

History: Lupus and RA run in both sides of the family. Patient’s relevant medical history dates to early childhood, diagnoses with diverticulitis at age of 13. Was on antibiotics for severe body acne for 18 years (age 14 to 32), during which time he became overweight; lost 60 lbs several years ago through a change in diet. Patient is type A, driven, hardworking; overly busy managing a growing small business, endemic high stress. Patient reports that getting angry causes all of his symptomology to worsen; alcohol, traveling, certain foods also causes exacerbation. Patient has had an elevated SED since onset of diverticulitis symptoms at age 13, as well as persistent iron-deficiency anemia and elevated EBV count.

Pulse: (R) soft, sunken, pronounced weakness of the Center qi. (L) 1st and 2nd positions wide, slippery-soggy with a thin wiry quality on top of the vessel, deep and soft in the 3rd.

Tongue: Thin white coat that is absent from outer 1/3 of tongue, moderate tooth marks, pale edges.

Previous treatment: Prior to and upon beginning treatment patient was undergoing pharmaceutical treatment under a rheumatologist. Medical technicians were unable to explain his symptomology or chronic levels of inflammation; best functioning diagnosis was Sjogren’s syndrome, Lupus, or psoriatic arthritis. Patient was taking a prescribed HCL blocker for the GI complaints, Valtex for elevated EBV, Allopurinol for gout, and sulfasalazine for the inflammatory bowel and arthritis pain. Patient’s condition continued to deteriorate, and was thus sent to my office for a second opinion.

Diagnosis: Deficiency of the Center Qi with Dampheat in the Liver/Gallbladder

Treatments Used: Herbs, acupuncture 2x weekly, colostrum.

Points Used: LI11, LI10, LI4, St36, GB42, SJ5, Ren12, LV3, KD9, HT3, Yintang, GB1, Du 20, Auricular: Shenmen, Point 0, Kidney, Liver, Spleen, Stomach, Heart.

Prescription: Xiao Chai Hu Tang + Bai Zhu & Sha Ren

Response: December 2014 – Present. As of two months ago nearly all of the patient’s symptomology has resolved. SED within normal range for first time since childhood; no anemia, no gout. Psoriatic skin patches are nearly fully healed, bowels are normal with no gastrointestinal pain or discomfort. Sweating is normal, energy is normal, sleep is best since childhood. No HEENT symptoms. Has begun meditating, eating on a schedule, sleeping on a schedule, and observing a better balance between work and family. He reports feeling “normal” and “happy” in a way he’s never experienced in his adult life. Patient still experiences transient swelling of the neck glands and mild joint pain in his hands when acutely stressed or the environment is damp or low pressure. This is considered an appropriate physiological response based on the patient’s constitution. Patient ceased all pharmaceutical medications last month and is in excellent health.

Comments: The patient presented with a complex array of symptoms that could easily overwhelm a practitioner or confuse the diagnosis. However, the presentation painted a clear picture of weakened Center Qi and an accumulation of dampness and heat in the Liver and Gallbladder systems. The tongue color confirmed the illness and the pulse its location. When treating the Liver one cannot address it solely or directly – restoring the Spleen is paramount. Akin to growing a garden this process takes time, the efficacy of which is clearly portrayed in the case history.

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