Disc protrusion - Bi-syndrome with cold-damp attack

[Michael]

SECTION 1: GENERAL INFORMATION
Sex: Female
DOB: 1952
Occupation: Farmer
M.S.: Married

[Michael]

SECTION 2: DATA COLLECTED FROM FOUR DIAGNOSTIC TECHNIQUES
2.1 INQUIRIES:

2.1.1 Chief Complaint: Intermittent right leg pain for 1 year, aggravated for month.

2.1.2 Present case history: The patient had intermittent right leg distending pain started form buttock radiated to the lateral-posterior of the shin for one year and aggravated since one month ago. Sometimes the numbness of the right foot was accompanied. The patient described that the pain often associated and aggravated with physical work and catching a cold; the pain relieved with a bending body posture or squatting. The patient felt pain at the lumbar region, and the right leg about 1 year ago and was diagnosed at her local hospital with disc protrusion. She has had been prescribed western medicine and acupuncture treatment.
15, 3-4/24   Menopause Feb 2003. 2-2-0-0

2.1.3 Previous history: No traumatic injury, no catching cold history.
2.1.4 Personal history: No drinking, no smoking, married with 2 children.
2.1.5 Family history: The patient had no family disease, no allergic.

2.2 INSPECTION/OBSERVATION:
2.2.1 Spirit: Consciousness: spirit – normal
2.2.2 Complexion: Skin and mucus – no jaundice, no bleeding. Sclera – Normal, no jaundice
2.2.3 Appearance: Facial crease normal. / Normal development / cooperate with doctor. / Tongue in the middle not deviated. / No oedema on both legs.
2.2.4: Body stature: Muscle strength – normal / Muscular tension – normal / Tendon reflex – normal / Skin sensation – normal / All neural responses were normal
2.2.5: Tongue: Slight red body, thin white coating
2.2.6: Other parts of the body: Pupil – symmetric, reaction normal.
Eye balls moves freely without tumbling. / Throat –reflex normal. / Neck – soft / Trachea – in the middle / Thyroid – normal / Thorax – symmetric
2.2.7 Excretion and Secretion: Bowel and urination were normal

2.3 AUSCULTATION & OLFACTION
2.3.1 Auscultation: N/A
2.3.2 Olfaction: N/A

2.4 Palpitation:
2.4.1 Pulse: Taut and thready pulse
2.4.2 Palpating different parts of the body: No knocking pain at the back.

[Michael]

SECTION 3: WESTERN MEDICAL RECORDS
3.1 Physical examination: (Positive signs)
Spinal cord normal, no knocking pain.   
3.2 Laboratory tests results: N/A

SECTION 4: DIAGNOSIS SUMMARY:
4.1 Chinese Medicine Diagnosis
Bi-syndrome with cold-damp attack.
4.2 Western Medicine Diagnosis
disc protrusion.

[Michael]

SECTION 5: DIFFERENTIATION AND ANALYSIS
5.1 List all the evidence of the differential diagnosis:
Yin Blood deficiency – over work, aging, after menopause.
Cold-dampness invasion – condition aggravated by catching cold.

5.2 Analysis of the Aetiology and pathogenesis
Due to Kidney and Liver Yin consumption by nature aging, the patient had Yin blood deficiency condition worsen by hard labor working. Working as a farmer also provided a more acceptable environment for catching cold-dampness. This caused the cold-dampness stagnation in the meridian and muscle causing pain, and Yin Blood deficiency unable to help nourish the muscles.
5.3 Principles of treatment:
1. Tonify Yin Blood. 2. expel cold-damp 3. regulate Qi and Blood, relieve pain
5.4 Prescriptions and Administration
BL23, 25, 32, 36, 37, 39, 60; GB30, 37 and SP9 on both sides.
Moxa on the pain area.
5.5 Measures of prevention and health care.
Avoid cold and dampness. Regular rest interval when working in the farm.