Balance system Acupuncture level 1/2
By Chiraphorn Bangsriwong, LAc.
Chief Complaint:
Male, age 52 presents to the clinic with a chief complaint of diarrhea, anxiety, and depression.
Present Illness:
Patient unemployment and get financial support from government. He tries to find the job and feel stressful. He cannot sleep well and thinking too much about life, have no desire for anything in life. He lives alone. Feel fatigued and tiredness during the day, poor appetite and feel anxiety when see a lot of people on the street. He doesn’t know why he live in this world and what he lives for. He takes antidepression drug and has been to anxiety group therapy which helped a little bit.
Most of the time diarrhea after eating, gastric discomfort, boating, and a lot of gas. At night wake up 1-2 time during the night to urine. No exercise. Always sweating daytime and nighttime, Patients said it side effect of HIV medication.
Past History:
Year first diagnosed with HIV: 1998 AIDS diagnosed:2/98
CD4 cell count:840 CD4% Date: 09/28/2016 HIV Viral Load <20 09/28/2016
Neutrophil Count 4.0x10E3x1000
Platelet Code 282x10E3x1000
Transmission Category: Bisexual
Operation/Specialists:
None currently.
Labs/Xrays:
TB Chest X ray: NAD (hyperinflation) 09/24/2008
Significant History Negatives:
TB Skin test Date 01/28/2015 Negative
QuantiFERON Test Date: Negative 09/28/2016
Medications/Supplements/OTC:
HIV medication
Anti-depression medication
Dietary Information:
Not noted.
Bowel and Urinary Habits:
Tends to be on the diarrhea side. Bowel movements are 1-3x/day after eating, Urination normal.
Sleep Habits:
Hard to falling sleep by himself need to take melatonin or Anti-depression medication help him to sleep.
Activity/Exercise: Not active.
Physical Appearance: Patient is of slightly skinny however his face appears pale and dark circle eyes.
Vital Signs:
Ht: 6’ 1” Wt: 160 lbs
Other Inquiry and Inspection:
SWEAT - sweating all the time
THIRST - normal
TEMPERATURE - gets hot easy, but cools quickly
ENERGY – Low 5/10
HEADACHES – sometime
APPETITE - Poor
STRESS/EMOTIONS - Anxiety has a general feeling of stress at 8/10
OTHER - memory and concentration are difficult.
Tongue:
Red on the side, sticky white coat, crack, scanty overall
Pulse:
L: thin, weak R: weak
Physical Exam:
N/A
Diagnosis:
TCM: Liver qi stagnation over acting spleen cause spleen qi deficiency.
CHANNEL Dx: Diarrhea and stomach discomfort.
Sick Meridien: KI, ST, SP, GB, LV
System1: HT, LI, LU, SJ, PC
System2: SJ, PC, SI, HT, LI
System3: BL, SP, ST, LV, GB
System4: LI, PC, SJ, HT, SI
System5: PC, LI, HT, SJ, LU
System6: KI, ST, SP, GB, LV
Treat: meridian is the most efficient choice for balancing: PC, ST, SP, SJ
Dynamic balance: Yin-Yang Flow
Static balance: The truss
Western: Diarrhea, digestive disorder.
Treatment:
Tx Principle: - Soothing the liver and tonify spleen.
- Clam shen
Tx 1: Global Balance
8 Magic points (+1) = 9 for overall digestive disorder.
PC connecting to ST by system 4
ST connecting to SP by system 3
SP connecting to SJ by system 4
SJ connecting to PC by system 3
GB connecting to SJ by system 5
HT connecting to SP by system 5
RIGHT: SJ5, Ling Gu (4.5) LEFT: LU7, PC6, HT5
RIGHT: SP9, LV8 (Dr. Tan’s liver point) LEFT: ST36, GB34 (Dr. Tan’s gallbladder point)
+ Yin tang, Du20, Sishencong
Rx: none.
Recommend: No spicy food, eat more healthy food such as onion and broccoli and exercise such as yoga and meditation at least 30 minutes a day.
REFERRALS: none
LABS: none
F/U/PLAN: Ax treatments at least 1/month for minimum 4 months because Being alive nonprofit organization, free of charge and have a lot of patients and can provided each patients only 1 time a month. During treatment acupuncturist combined Infrared, musical, aroma and massage therapy.
OTHER: Focus on stress-reduction and self-care.
Results:
This patient had immediate relief of his symptoms after his first treatment. He feels so relax, stress relieved and felt less anxiety. Patients cry because emotional and he said he never feel like this before, His body feel light and floating. Boating in the stomach feel better.
Tx 2 : 8 Magic points (+1) = 9
8 Magic points (+1) = 9 for overall digestive disorder.
Overall digestive disorder.
RIGHT: SJ5, Ling Gu (4.5) LEFT: LU7, PC6, HT5
RIGHT: SP9, LV8 (Dr. Tan’s liver point) LEFT: ST36, GB34 (Dr. Tan’s gallbladder point)
Rx: none.
Recommend: Maintain balance diet and exercise also social interact with friend and family.
REFERRALS: none
LABS: none
F/U/PLAN: Come next appointment on next month.
OTHER: Focus on self-care and digestive problem.
Results:
This patient come back with improved a lot with overall health, Patient said stomach discomfort get a lot better boating and gas in the stomach get better but still have diarrhea sometime. Patients avoid spicy food and eat more healthy food. He let it go a lot of things and right now feel a lot better with anxiety and depression, have more energy also get the new job at movie theater near our clinic after walk by and get interview. Patient appreciated and said acupuncture help him a lot.
Tx 3: 8 Magic points (+1) = 9
Overall digestive disorder.
RIGHT: SJ5, Ling Gu (4.5) LEFT: LU7, PC6, HT5
RIGHT: SP9, LV8 (Dr. Tan’s liver point) LEFT: ST36, GB34 (Dr. Tan’s gallbladder point)
Rx: none.
Recommend: Maintain balance diet and exercise also social interact with friend and family.
REFERRALS: none
LABS: none
F/U/PLAN: Come next appointment on next month.
OTHER: Focus on diarrhea problem.
Results:
This patient feel relax and stomach boating has been relieved. He wants to go restroom after the treatment finish. Patient start new job and he feel so happy, anxiety and depression coming sometime at night when he cannot sleep. He does meditation when he feels anxiety and he don’t want to take Melatonin and anti-depression medicine because it not good for his health, also he needs to take HIV medicine for long term. He starts exercise, eat healthy food, and go gym 3 time a week.
Tx 4: 8 Magic points (+1) = 9
Overall digestive disorder.
RIGHT: SJ5, Ling Gu (4.5) LEFT: LU7, PC6, HT5
RIGHT: SP9, LV8 (Dr. Tan’s liver point) LEFT: ST36, GB34 (Dr. Tan’s gallbladder point)
Recommend: Maintain balance diet and exercise.
OTHER: Focus on self-care.
Final Results
This patient had immediate relief from his anxiety and depression symptoms after his first treatment. The patient feels relaxed and relieved from stress. Continued treatments were done once a month. After the fourth treatment with the eight magic points + one, his discomfort stomach and diarrhea began to diminish. Eight magic points help the patient to relieve so much, his sleep was also consistent at 6-7 hours without sleep medication. Patients still feel depression and anxiety but less and have more energy improved at 8/10. Patients do yoga exercises, and meditation helps them a lot at home. The patient said acupuncture change his life and feel happier in life. It was recommended to the patient follow up more.
References
In memory of Dr. Richard Tan. (2019). 8, 10. From https://www.simonaltman.com/wp-content/uploads/2019/04/Dr-Tan-Matrix-V8.1.pdf
Tan, D. S. (2020). The Foundations of Balance Acupuncture : A Clinical Reference Manual.