Facial paralysis - Wind-cold attack with liver yang rising

[Michael]

SECTION 1: GENERAL INFORMATION
Sex: Male
DOB: 1947
Occupation: Nil
M.S.: married

SECTION 2: DATA COLLECTED FROM FOUR DIAGNOSTIC TECHNIQUES
2.1 INQUIRIES:
2.1.1 Chief Complaint: Deviation of mouth toward right side of the face for 13 days.

2.1.2 Present case history: The patient woke up in the morning 13 days ago with sudden onset of mouth deviation and accompanied with left eye lid unable to close, left forehead ring cal disappeared, and left facial crease disappeared. There was slight left eye infection due to the lacrimation of the left eye.

2.1.3 Previous history: Before the onset of the symptoms, the patient had hard labor work and exhausted himself and caught a cold.
2.1.4 Personal history: No drinking, no smoking.
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, slight redness on the left eye due to lacrimation caused infection.
2.2.3 Appearance: Left facial crease disappeared, left fore head ring cal disappeared. / Normal development / Walk normal, cooperate with doctor. / Tongue deviated to the right.
2.2.4: Body stature: Muscle strength – normal, left eye lid unable to close
2.2.5: Tongue: Red body, thin white coating
2.2.6: Other parts of the body:
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 N/A

2.4 Palpitation:
2.4.1 Pulse: Strong pulse
2.4.2 Palpating different parts of the body: no pain behind the scalp, no pain behind the ear.

[Michael]

SECTION 3: WESTERN MEDICAL RECORDS
3.1 Physical examination: (Positive signs)
Deviation of the mouth to the right, unable to close the left eye lid.
3.2 Laboratory tests results:
ECG, Ultra-sound, Blood tests all normal.

SECTION 4: DIAGNOSIS SUMMARY:
4.1 Chinese Medicine Diagnosis
Facial paralysis due to Wind-cold attack with liver yang rising.
4.2 Western Medicine Diagnosis
Facial paralysis.

[Michael]

SECTION 5: DIFFERENTIATION AND ANALYSIS
5.1 List all the evidence of the differential diagnosis:
Facial paralysis – deviation of the mouth and lost of facial crease. Wind-cold attack in the facial meridian and history of catching cold before the onset of the symptom.

5.2 Analysis of the Aetiology and pathogenesis
The Liver yang rising redeposit the facial paralysis is due to consumption of Liver yin resulting symptoms on the upper part of the body. Liver and Spleen disharmony also aggravated by over work consumed Spleen Qi. Spleen deficiency further allowed external wind-cold attack, caused facial deviation.

5.3 Principles of treatment:
Calm Liver yang, Tonify Liver Yin, regulate Qi, expel wind-cold.

5.4 Prescriptions and Administration
ST2, 3, 4, 6, 7, 8; LI4 on both sides of the body. Needle retention for 1/2 hour.
Moxa through ginger on the left face and fore head.
One course treatment of 10 times.

5.5 Measures of prevention and health care.
Not to catch cold.