Vertigo - Spleen Qi deficiency, and clear yang unable to ascend to the orifices

[Michael]

SETCION 1: GENERAL INFORMATION
Sex: Male
DOB: 1971
Date of First Visit: 12th Feb 2003

SECTION 2: DATA COLLECTED FRM FOUR DIAGNOSTIC TECHNIUES
2.1 INQUIRIES:
2.1.1 Chief Complaint: Dizziness, double vision for 1 month.
2.1.2 Present case history: Since 5th Jan. 2003, while when the patient was driving, he got tinnitus, dizziness and double vision. There were no weakness of the legs and he sought for medical attention and had some treatment. After the treatment, the tinnitus and double vision were relieved, but dizziness had remained. He went to ShangHai CangHai hospital and had MRI examined. The result shown abnormal signals in left cerebellum, and it was suspected to be encephalitis.

Test for hearing had negative finding, however the patient had minor muscle paralysis. The ShangHai CangHai hospital had diagnosed him with infarction of cerebellum.
CSF test was normal.
The patient had treatment for the dizziness with cortisone for 1/2 month, but the effect was in vain. The dizziness was aggravated when he was in standing posture.
Normal appetite
There was no fever since onset of this condition, no numbness of he limbs, no unstable walking and no incontinence of bowel and urination.
2.1.3 Previous history: Before the onset of the disease, the patient had respiratory tract infection. There was no history of hypertension, no hepatitis, no T.B., no typhoid, no trauma.
The patient was neither a smoker nor a drinker.
2.1.4 Personal history:
No drinking, no smoking, married with one son.
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
Walk normal, 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: dark red body, thin 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:
Respiration sound – normal, no rale sound, heart rate 82 beat/min – regular.
No pathogenic murmur sound.
2.3.2 Olfaction: N/A

2.4 Palpitation:
2.4.1 Pulse: Taut pulse
2.4.2 Palpating different parts of the body:
Palpation: can not palpate lymph nodes.
Abdominal palpation – soft, no palpable tenderness.
Liver and Spleen were not palpable
Murphy sign – negative

[Michael]

SECTION 3: WESTERN MEDICAL RECORDS
3.1 Physical examination: (Positive signs)
T(36.9oC), P(82 beat/min), R(20 breaths/min)), B(120/64 mmgH)

3.2 Laboratory tests results
Lab test: MRI 0 abnormal at left cerebellum, indicate possible infarction .
CST – normal
Blood flow – normal – blood viscosity normal
ECG – Normal
Routine urine test – normal
Routine stool test – normal

SECTION 4: DIAGNOSIS SUMMARY:
4.1 Chinese Medicine Diagnosis   
Vertigo with Spleen Qi deficiency, and clear yang unable to ascend to the orifices.
4.2 Western Medicine Diagnosis
Vertigo

[Michael]

SECTION 5: DIFFERENTIATION AND ANALYSIS
5.1 List all the evidence of the differential diagnosis:
Dizziness - Heart shen disturbance, and clear yang not filling the clear orifice.
Tinnitus – Internal wind disturbing ear orifice.
Weakness of the legs – Spleen deficiency due to over work.

5.2 Analysis of the Aetiology and pathogenesis
Due to fatigue and Zheng Qi deficiency, it resulted in Wei Qi deficiency and allowing pathogen to ascend to the head and caused disturbing of the heat shen (mind). Zheng Qi deficiency unable to raise clear yang Qi to nourish the brain and the clear orifices; this resulting in Dizziness.

5.3 Principles of treatment:
Ascending clear yang, expelling internal wind

5.4 Prescriptions and Administration
Tian Ma10, GouTeng30, ChuanXiong10, DanSeng30, ShiChanPu10, YuJing10, DaoRen10, GeGen30, ShenMa10, YuanZhi6, BanLanGen30
After taking formulae for 3 days, dizziness relieved, vision improved. On 18th Feb 2003, changed formulae to resolved phlegm and calm the min, opening the clear orifices.
ShiChanPu10, YuJing10, TiuanZhuHuang10, GeGen30, ChuanXiong10, GuanZhong10, HeYe10, DanSeng30, ManJingZi10, BaiJiLi15, ZhenZhuMu30, SuanZaoRen10.