Knee Pain and Shoulder Pain

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Patient info: female, 74 years old. Return Patient.

Date of visit: 2016-03-17

Chief complaint: patient experiences knee pain when walking downstairs. Pain of the right shoulder due to lifting boxes, but R.O.M. is good.

Findings:

Digestion/bowel movements are good, sleeping well. Energy level is 7/10.

Tongue: scarlet-red, dark, teeth-marks, central crack.

Pulse: thready, wiry, deep.

Assessment:

Bi syndrome, Qi and blood deficiency leading to blood stasis.

Treatment Principle:

Acupuncture LI11,TW14 and LI15(Lt),LI4,LI11,SP10,ST38(LT),TW4,GB34, Heding (RT).

Formula: Du Huo Ji Sheng Tang.

 


Date of Visit: 2016-03-24

Patient's right knee is still aching, but feels better after the last treatment, patient has been walking more. Shoulders still feel sore.

Findings:

No issues with digestion, sleep, energy. Non-pitting edema on the lower limbs. Patient is planning to get a hearing test today.

Tongue: red with thin white coating, deep, short cracks, slightly deviated to the RT.

Pulse: full, deep, weak on both kidney positions.

Assessment:

Continue acupuncture treatment.

 


Date of Visit: 2016-03-31

Achy knees and shoulders continuously to improve, but having dry eyes, dry throat and dry skin for about a week.

Findings:

Slight lower leg edema. Patient has no other complaints.

Tongue: purple body,peeled, cracks.

Pulse: medium force, deep, smooth (LT), slow and full (RT).

Assessment:

Blood stasis leading to dryness.

Treatment Principle:

Acupuncture ST36, SP6, GB37, TW3, GB39, KI7 (RT), Xi Yan (RT).

 


Date of Visit: 2016-04-28

This is the fifth visit for knee pain and shoulder pain, also had acupuncture treatment for over all dryness as stated previously.

Chief complaint: 

Much has improved, only the right shoulder feels achy, sometimes crampy.

Findings:

Knees-good,energy-good,sleep-good,digestion-good.

Tongue: short,swollen,red.

Pulse: LT-big,deep, RT-slippery,rolling.

Assessment:

Pain Bi,Damp/heat T

Treatment Principle:

Acupuncture SP9, UB60, LI3, LI11, ST40, LV3, GB41.

 


Date of Visit: 2016-05-05

Chief complaint:

Reoccurring achy knees and lower energy.

Findings:

Digestion and sleep are good.

Tongue: short, red, swollen, small cracks.

Pulse: LT: full, deep; RT: slippery, full, deep.

Assessment:

Spleen Qi deficiency, Kidney Yin deficiency with heat, dampness.

Treatment principle:

Acupuncture SP9, KID3, ST36, LI11, KID9, SP6, LU7, He Ding, Xi Yan.

Reflexology on the feet.

 


Date of Visit : 2016-05-12

Chief complaint: loose stool, bloating.

Findings: Tongue: short, cracked, swollen. Pulse:full, large.

Assessment: Spleen and Stomach Qi rebellion, dampness.

Treatment plan: SP9, ST 40, SP 3, REN 9, REN12, ST 36. Herbal formula: Si Jun Zi Tang.

 

Date of Visit: 2016-05-26

Chief complaint: upset stomach, nervousness.

Findings: energy-ok, sleeping well. Tongue: swollen, cracked,purple. Pulse: deep, forceful.

Assessment: Liver Qi stagnation, Liver overacting on Spleen.

Treatment plan: SP9, LIV 3, LIV 13, REN 6, REN 12, ST 36, KID 6.

 

Date of Visit: 2016-06-02

Chief complaint: shoulder pain, knees ache, feet feel swollen (lower leg and feet edema).

Findings: Tongue: short, red, cracked, moist, no coating. Pulse: full, rapid, forceful.

Assessment: heat, blood stasis, Qi stagnation.

Treatment plan: SP4, LIV 2, LI 4, SP 9, SP 10, LI 11, ST 36, ST 38 (RT), KID 6, SJ 4. Herbal formula: Tao Hong Si Wu Tang.

 

Date of Visit: 2016-06-16

Chief complaint: RT shoulder pain, knees ache, but the patient is feeling much  better overall.

Findings: Energy-good, digestion-good, sleeping well. Tongue: short, swollen (LU area), peeled, cracked. Pulse: LT: deep, wiry; RT: full, surging.

Assessment: Qi and blood stasis.

Treatment plan: SP 9, SP 10, ST 36, LU 9, SJ 3, SP 5, SP 6, He Ding. Foot reflexology. Ear seeds: LU, ST, HT. Herbal formula: Tao Hong Si Wu Tang (2nd bottle).