Case Study 2

CASE STUDY 2

Patient:

Female, 38 y.o.

Main Complaint:

Patient came to me with the complains of joint pain and swelling due to Rheumatoid Arthritis. She experiences sharp to dull aching pain in mainly her left knee and right ankle. Both swell significantly during flares. She has occasional pain in her other knee and ankle and PIP/DIPS. Flares occur anywhere from once a week to once a month.

Secondary Complaint:

Patient has a Multiple Sclerosis diagnosis and has occasional weakness and pain in her right arm. She doesn’t have any other physical symptoms causing her discomfort at this point.

OM History:

No headaches, no tinnitus, occasional foggy mind, no floaters, no palpitations, no sob, good appetite and digestion, no gas/bloating, occasional constipation due to medications, urination normal, no low back problems, low stress, exercises regularly and eats a well balanced diet, menstrual cycle is normal, poor sleep, night sweats, cold hands and feet, dizziness, anxious and irritable mood.

History:

Rheumatoid Arthritis, Multiple Sclerosis.

Medications:

Naproxen, Copaxone, Orencia.

Pulse:

Wiry

Tongue:

Slightly dusky with a thick white coat and distended veins.

Diagnosis:

Rheumatoid Arthritis and Multiple Sclerosis.

Differentation:

LV/KI Yin Xu with LV Qi Yu, LV Xue Xu and Damp Retention.

Treatment Principle:

Nourish LV/KI Yin and LV Xue, Soothe LV Qi and Drain Damp.

Points and Methods Used:

3 Intelligent Points; Yintang; RN 17, 6; Buddha’s Triangle; 4 Gates; SI 3; SP 10, 9, 6; ST 36, 40; GB 34, 39, 41; LV 8, 3 or 2; KI 8, 6; BL 62. When her knee does hurt I apply Estim at Xiyan.

Herbs Prescribed:

None.

Results:

Main Complaint:

Patient experienced significant results after one treatment but initially still experienced flares in between sessions thereafter. After 6 months of consistently weekly treatment, her flares greatly subsided as well as the pain and swelling. Shortly after this time period, the patient made the decision to try to get pregnant. Therefore, her other physicians took her off of her naproxen, copaxone and put her on a monthly dose of orencia. She had trouble again with flares, pain and swelling for the first 2 months after going off of her medication. We continued weekly treatments. After another 6 months of consistent treatment, totaling a year of continued weekly treatments, the patient rarely gets flares anymore and her pain and swelling level are almost non-existent. She will however, experience a flare or pain and swelling directly related to periods of extreme stress. Once an acupuncture treatment is done it all disappears again. She is still off all but one of her medications.

Second Complaint:

After a year of consistent weekly treatment, the patient had an MRI and it revealed that since her last MRI 2 years before, the lesions on her brain from the MS have not grown in size. Before acupuncture they grew consistently every year. That growth has stopped or slowed to an immeasurable amount.

Conclusion:

This patient came to me after suffering the symptoms of Rheumatic flares, pain and swelling and a diagnosis of MS since she was in her early 20s. Conventional drugs have helped her some but once acupuncture was introduced she improved in leaps and bounds as she never had before. Even after stopping some of the medications that had been helping, with weekly treatment she continues to improve! Her current differentiation is just LV Qi Yu except when she has an occasional flare, swelling or pain the Damp component rears its head. Her tongue is normal with occasional teeth marks but no longer does she have distended veins or a thick white coat. In her words, she feels amazing!

Definitions:

Rheumatoid arthritis - is a chronic inflammatory disorder. It typically affects the small joints in your hands and feet but can also affect the larger ones such as the hips, knees and ankles. Unlike osteoarthritis, which is due to wear and tear of the joints, rheumatoid arthritis affects the lining of the joints, causing a painful swelling that can eventually result in bone erosion and joint deformity.

This is an autoimmune disorder. When rheumatoid arthritis occurs the immune system mistakenly attacks your own body's tissues. In addition to causing joint problems, rheumatoid arthritis can also affect your whole body with fevers and fatigue.

It is much more common in women than in men and generally occurs between the ages of 40 and 60. Treatment focuses on controlling symptoms and preventing further joint damage.

Multiple sclerosis (MS) - is a potentially debilitating disease in which the body's immune system eats away at the protective sheath (myelin) that covers your nerves. Damage to this tissue myelin causes interference in the communication between the brain, spinal cord and other areas of the body. This condition may result in deterioration of the nerves themselves, this process is not reversible.

The symptoms vary widely, depending on the amount of damage and the nerves that are affected. People with severe cases of multiple sclerosis may lose the ability to walk or even speak clearly. Multiple sclerosis can be difficult to diagnose early in the course of the disease because symptoms often come and go. They sometimes can disappear for months.