Patient”s  name : Anne

Date of Birth : 29-07-1979

Sex : Female

Marital status : Married

Occupation : Teacher

Chief  Complaint menopause , poor sleep , skin irritation :.

Date of first consultation and treatment : 16-08-2010

Present symptoms of illness :.

over one year she often feel inexplicably fatigue, restlessness, lack of interest in anything, poor sleep, poor appetite, hot flash and night sweating, chest discomfort, a sense of pains and needles feeling , numbness, itching feeling on her skin, mainly on her legs and arms , recently also on her chest and back , specially after shower feeling worst , but Look at the skin, not red not swollen , her mood swiping . easy to cry  .

History of current illness : She has been amenorrhea about eight month , also

She has been pains and needles feeling about 18 years , due to she was study at that time , she stressed , anxiety , poor sleep , since then she had this pains and needles feeling .

Family medical history : her father and her uncle have had pains and needle feeling on their body as well .

Modern medical diagnoses : Menopause , Allergy of water

Traditional Chinese medicine diagnoses :  Zang Zao

Some additional check : Blood pressure 120/75 mmhg , Heart rate 80 t/m , Temperature 36.5c .

Tongue inspection : tongue is deep red with thick coating , slightly greasy coating , white color .

Pulse condition : wiry and thin pulse .

Syndrome differentiation : Yin deficiency with upward-flaming fire . and sooting the liver qi to relieve depression .

Treatment Principles :Enriching yin , supplementing the kidney , clearing deficiency-heat , coursing the liver and dispelling depression , regulating moods , arousing the brain and calming the mind .

Prescription :

Acupuncture and electric needle points : BL18 ,BL15 , BL23 , BL52 , GV 20 , GV24 , EX-HN 3 , GB 20 , GV14 , PC 6 , SP 6 , KI 3 , KI1  , KI7 . C V 17 , C V 12 .

Herbs prescription cai hu , yu jin , bai shao , zhi mu , huang bai , sheng di , di hu pi , dan pi , zhi zi , wu wei zi , huang qi , gan cai .

Others : . jing xin ko fu ye , xue fu zhu yu wan , gan mai da zhao wan .

Analysis :

This patient ‘s syndrome due to chronic disease and improper regulation ,consumption of liver and kidney  yin fluid and failure of yin to control yang the results are liver –kidney yin deficiency , interior impairment by emotional disorder , insufficiency of the sea of marrow , deficient fire flaming upward , spirit orifices failing to be nourished . so she had symptoms as mood swiping , easy crying  due to the liver qi stagnation and spirit orifices failing to be nourished , insomnia dreaminess are cause  by interior heat disturbing mind due to yin asthenia , hot flash and night sweating , reddish tongue , thin and rapid pulse are the signs of lack of moistening due to yin asthenia and interior exuberance of asthenia fire , pains and needles feeling due to autonomic nervous system instability cause abnormal skin sensation .

Tai xi (K I 3) , the Yuan-Source point of the kidney meridian and key point for enricjing and supplement kidney yin , can enrich water and supplement kidney when combined with B L 23 and B L 52 ; K I 1  , located at the soles and the jing-well point of kidney meridian , is drained to conduct deficient fire of the kidney meridian downward , calming the spirit . G V 25 , at the vertex of the heat , links the brain orifice , so it can be supplemented to boost the sea of marrow ; B L 18 can dispel liver depression ; P C 6 and C V 17 are needled to free the chest and rectify qi , move qi and release depression ; H T 7 , the source point of the heart meridian , is where it passes through bearing its original qi and is also the gate for heart –spirit to enter and exit , it is said that ‘the source point should be selected to treat the disease of five zang organs’ , it is also a key point for quietening the heart-spirit , and supplementing the point can strengthen heart qi and nourish heart blood . .the combination of the above mentioned points can achieve the therapeutic effect of enriching yin , supplementing kidney , clearing deficiency heat and the liver , dispelling fire and calming the mind

Follow –up /Course of treatment (one week later)

Second consultation: this patient slept well at same night after acupuncture , but after three days , her sleeping is back as befor , none anxiety feeling , mood smooth , hot flash and night sweating has been reduced ,  none chest discomfort , energy has been better , even pains and needles feeling has been reduced a lot after shower , she felt so relex and comfortable of  herself .

Tongue inspection Red tongue with thin coating .

Pulse condition : wiry and thin pulse .

Prescription :.

Acupuncture points : BL18 ,BL15 , BL23 , BL52 , GV 20 , GV24 , EX-HN 3 , GB 20 , GV14 , PC 6 , SP 6 , KI 3 , KI1  , KI7 . C V 17 , C V 12 .

Herbs prescription : cai hu , yu jin , bai shao , zhi mu , huang bai , sheng di , di hu pi , dan pi , zhi zi , wu wei zi , huang qi , gan cai .

Others : . jing xin ko fu ye , xue fu zhu yu wan , gan mai da zhao wan .

Analysis

Due to this treatment was effected on this patient , so  i prescribed same treatment for this patient again .

Third weeks consultation :

After two session of the treatment , this patient’s stress and anxiety has been much improved , her sleeping can go through for  whole night at least two night , hot flash and night sweating has been reduced at least 70% , this patient could again concentrate on her work , pain and needles feeling  on her back and chest are gone , but still left about 30% on her low legs after shower , some times this patient still feel little bite itching of her skin .

Tongue inspection : tongue is red , thin coating , white color .

Pulse condition : wiry pulse .

Prescription :.

Acupuncture points :  BL18 ,BL15 , BL23 , BL52 , GV 20 , GV24 , EX-HN 3 , GB 20 , GV14 , PC 6 , SP 6 , KI 3 , KI1  , KI7 . C V 17 , C V 12 .

Herbs prescription : dan shen ,  nv zheng zi , han lian cao ,  bai shao , sheng di ,  dan pi ,  wu wei zi  , ye jiao teng , xian mao , xian ling pi , gou qi zi , ji xue teng , ju hua , gan cai .

Others : . jing xin ko fu ye , jiao wei xiao yao wan .

Analysis :

This patient’s symptoms has been much improved , now I decided keeping same acupuncture treatment , but change her herb formula , due to this patient still has  abnormal skin sensation , traditional Chinese believe causing abnormal skin sensation by blood deficiency and heat of blood , this patient has been stress and same skin proberlem for eighteen years ,leading to a condition in whichthe liver fails in its free coursing and blockage of qi is present , in turn , results in the transformation of lasting depression into fire , so I prescribe different herbs from last treatment , to clean up heat of her blood and nourish her blood of yin  .

Fourth weeks consultation

This patient’s abnormal skin sensation has been much improved , some days just a little pain and needles feeling , some days none , no itching feeling , other symptoms has been continue improved , three or four days even no hot flash and night sweating , some times just a little on her forehead .

Tongue inspection : tongue is light red with thin coating , white color .

Pulse condition : wiry pulse .

Prescription :.

Acupuncture points :  BL18 ,BL15 , BL23 , BL52 , GV 20 , GV24 , EX-HN 3 , GB 20 , GV14 , PC 6 , SP 6 , KI 3 , KI1  , KI7 . C V 17 , C V 12 .

Herbs prescription : dan shen ,  nv zheng zi , han lian cao ,  bai shao , sheng di ,  dan pi ,  wu wei zi  , ye jiao teng , xian mao , xian ling pi , gou qi zi , ji xue teng , ju hua , gan cai .

Others : . jing xin ko fu ye , jiao wei xiao yao wan .

Analysis :

Due to this treatment was effected on this patient , so  i prescribed same treatment for this patient again .

Fifth weeks consultation

This patient’s symptoms continually are improved , none hot flash and night sweating  , this week none pain and needles feeling on her low legs after shower , none itching , sleeping was good , her mood serene , energy was good , long time she never feel as good as now .

Tongue inspection : tongue is light red with thin coating , white color .

Pulse condition : wiry pulse .

Prescription :.

Acupuncture points :  BL18 ,BL15 , BL23 , BL52 , GV 20 , GV24 , EX-HN 3 , GB 20 , GV14 , PC 6 , SP 6 , KI 3 , KI1  , KI7 . C V 17 , C V 12 .

Herbs prescription : dan shen ,  nv zheng zi , han lian cao ,  bai shao , sheng di ,  dan pi ,  wu wei zi  , ye jiao teng , xian mao , xian ling pi , gou qi zi , ji xue teng , ju hua , gan cai .

Others : . jing xin ko fu ye , xiao yao wan .

Analysis :

Due to this treatment was effected on this patient , so  i prescribed same treatment for this patient again.

Discussion :

Due to the decline of ovarian follicle decrease with ageing, changes in sex hormone synthesis, neuroendocrine disorders, decreased immune function, etc., in addition to menstrual disorders, it will also appear upset, irritability, dizziness, palpitations, fatigue, insomnia, forgetfulness , hot flashes, night sweats, joint pain, perceived allergies, increased urination.  These are the main symptoms of autonomic dysfunction, known as the “menopause”. Hot flashes are premenopausal and postmenopausal women have characteristic symptoms.

Due to the vasomotor symptoms of functional instability.

This patient is at postmenopausal stages, apart from mental and psychological symptoms she also has symptoms of autonomic nervous system instability.

She had those problems for a long time, causing her symptoms getting worse gradually, since taking the traditional Chinese medicine, her symptoms are much better, this means apart from using western medicine, Chinese medicine treatment is also a successful therapy for patients who suffer from menopause.