Current Symptoms: Patient presents with acute headaches, increasing in frequency and intensity for 4 months - temporal, orbital, and posterior - neck pain, shoulder pain, bi lateral hip pain, pain refers down right leg - low back pain, intrascapular pain (pain between shoulder blades), stress, insomnia, low energy, abdominal pain
Subjective: (patient's description of symptoms) deep, dull, throbbing and aching sensation in temples, around eye, and back of head, consistent throughout days and nights. Right side of neck feels tighter. Right shoulder tighter.Right hip and leg feel tighter. Symptoms have been consistently more painful and restrictive on the right side.
Objective Findings: Palpation of muscles, joints and points finds illiopsoas, gluteus minimus, trapezius, and other associated neck and shoulder muscles, cervical 3 tighter on left, cervical 6 tighter on right, vascular compression in both thighs are tight and reactive to palpation. Abdominal palpation finds liver blood inhibited, endocrine dysfunction of thyroid and adrenal glands. pulse palpation finds liver inflammation, stomach inflammation, endocrine weakness.
Assessment: Liver blood circulation inhibited creates inflammation in liver. other abdominal circulation inhibition creates stomach inflammation. In chinese medicine blockages often become pathogenic inflammation at first. Later, blockages will lead to deficiencies, as affected regions lose their supply and drainage functions, and over all function become lower.
Treatment: acupuncture was applied to affected channels, liver, stomach, and local associated musculo-skeletal regions. neck, trapezius, hips, abdomen, back.
Results: After 1 treatment headaches were completely resolved. Neck and shoulders were much improved. Abdomen, leg and hip also felt much improved.
2nd Treatment: After 2 weeks, headache had returned 20%. hip, abdomen, leg pain, had remained improved. After the 2nd treatment, the headaches resolved again. other pain also improved.
3rd Treatment: After 2 weeks, headaches returned 10%.. other pain continued to improve significantly. energy and sleep were also improved.
4th Treatment: After 2 weeks. the headaches did not return, and have not returned in all subsequent visits. hip, leg and abdomen have very mild symptoms.
The patient has been able to return for treatment every 2-3 weeks, for 6 treatments. As the patient's pain gets better they notice other improvements. Strength and balance are noticeably improving. They notice they are more stable on their feet. They are less affected by stress. They have better stamina for exercising and walking, and feel overall more flexible.
The patient was then prescribed herbs and her energy and sleep continued to improve greatly after herbal treatment. The herbal treatment focused on clearing liver and stomach inflammation, promoting circulation in liver and abdomen, nourishing energy of adrenals and thyroid.