Clinical Case: Female 45 Years Old, Whole Body Pain

Clinical Case: Female 45 Years Old, Whole Body Pain

Female, 45 years old

Reason for consultation

Chief complaint: tremendous pain all over the body,

Location: generalized all over the body (legs and joints)

Duration: for 6 years

Initially headache (eyes and temples, as if in a vise), weakness of strength, very exhausted. Loss of balance, vertigo, dizziness. Visual weakness, constant at night and during the day. Notices it more with weather changes. Chills, sometimes feels very cold sometimes very hot. The left side of the body is more affected (where she had a minor stroke). Sleeps poorly: early-night insomnia and after an hour and a half may be awake due to the pain. Digestion: has reflux, has one bowel movement a day but struggles without taking anything.

Things fall from her left hand, tingling. May fall due to left leg.

Loss of vision on the right side, after a flare-up.

Takes ibuprofen and something else...

Diagnosed with chronic fatigue. Also has demyelination at cerebral level (possible multiple sclerosis), each flare-up worsens mobility and memory (forgets where she has put things).

Blood pressure with tendency to be low.

Frequent urination (3 times at night) and abundant. Sometimes has to rush to urinate.

Weak nails and hair.

Tongue with yellow coating (retracted)

Pulse


Diagnosis

Bi Syndrome (pain, interior or exterior) and Wei syndrome (hypofunction, zang fu).

It is Wind Bi, due to generalized pain that worsens with climate changes.

Empty pattern of Liver, Kidney and Spleen.


Treatment

  • Move energy and generalized pain: BL-43
  • Generalized pain: SP-21 (great luo)
  • Shao yang and pain: TE-5 + GB-41 (Yin/Yang Wei Mai), GB-20 + GB-39 (fundamental, great point of the head)

Empty pattern, yuan points: LR-3 , KI-3, SP-3

Generalized pain: LR-8

Tonify energy: CV-6, BL-23

Moxibustion where possible.

Authors:

Page updated on December 28, 2015

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