Five Virtues Center for Acupuncture Case Study: Headaches and Amenorrhea By Ross Rosen and Jennifer Sobonski History: Patient is a 15- year- old girl who was referred with headaches and amenorrhea. Her headaches began after she was hit in the head with a volleyball. She developed severe migraines, dizziness and balance issues leaving her on bed rest and out of school. She was seen by a neurologist, was prescribed medication and underwent an MRI. The MRI was negative and was diagnosed with a concussion. After two weeks of being out of school and not having any changes in her dizziness or migraines, her parents wanted to give Chinese medicine a try. The patient was simultaneously dealing with irregular menses since her period began. Her menses began at the age of 12 and generally lasted from 3-5 days. It was never regular from the first cycle. She would go as far as four months without a period. At the time of the initial visit she had not had her menses for three months. Health Status: Digestion: not remarkable Appetite: not remarkable Urine: not remarkable Stool: 1x/day on most days; well- formed Temp: runs cold Sweat: not remarkable Chest: Exercise- induced asthma Thirst: not remarkable Skin: acne on face, chest, upper back Energy: lethargic and fatigued Sleep: trouble falling asleep and often wakes up to urinate Emotions: Increased irritability and impatient Head/Eyes/Ears: Migraines (daily): diffuse over entire head and throbbing; constantly dizzy Menses: irregular (see above) Past Medical History: 1998: born C- section secondary to being breach 2001: parents divorced
Family Health History: - Grandmother died of lung cancer Allergic History: none Physical Examination: a. Tongue: red, thick brown coat in kidney/bladder/intestinal area, very red with petechia in the heart area and lighter red petechia from stomach/spleen area- lung. Rough: Lung area and coat in the heart area. b. Shen: animated c. Listening and Smelling: weepy voice Pulse Diagnosis: I. OVERALL: a. Qi stagnation, Heat, Yin deficiency changing to reduced substance: Qi Wild presentation b. Heart Qi agitation/heart Shock c. Stagnation of all substances: depression d. Significant Qi deficiency II. Heart Position: a. Qi and yang deficiency b. Significant blood deficiency c. Shock III. Liver Position: a. Qi stagnation, Yin deficiency b. Damp- heat c. Neoplastic (potential) activity (muffled +3) changing to absent changing to empty: Separation of Yin and Yang d. GB: inflamed and neoplastic (potential) IV. Kidney Yin: a. Blood/Essence deficiency b. Neoplastic activity (severe)- potential c. Qi deficiency and stagnation d. Damp- heat V. Lungs: a. Qi and Yang deficiency b. Special Lung Position; severe impaired functioning and Qi stagnation VI. Digestive: a. Qi stagnation and deficiency b. Spleen Qi deficiency severe: separation of yin/yang c. Damp- heat d. Potential neoplastic activity (muffled +3)
e. Blood stasis VII. Kidney Yang: a. Qi stagnation and heat (significant) b. Neoplastic activity- potential c. Impaired function (amplitude changes +3) Treatment/Management Plan: (prioritizing our interventions) I. Immediate Interventions a. Stability: i. Heart Shock: blood stasis, rough vibration, change in rate at rest, amplitude changes, qi and yang deficiency ii. Separation of Yin and Yang: Liver and Spleen iii. Overall: Qi Wild; stagnation/heat changing to reduced substance b. Circulation/Heat: i. Lung/Chest: impaired function ii. Neoplastic activity: KI/PLB/LR/ST iii. Toxicity: Liver II. Root: a. Kidney: essence and blood deficiency b. See 1a above c. Lung Qi and Yang deficiency III. Secondary: a. Damp- heat in the middle Jiao- lower Jiao b. Qi stagnation/heat/blood stasis c. Pelvic Lower Body: neoplastic activity d. Stomach: qi stagnation and stasis Discussion: The patient s symptoms are the result of a constitutional weakness resulting in the straw that breaks the camel s back scenario. This patient s pathology is rooted in constitutional, conception, and lifestyle factors. Upon questioning further, the patient s mother had a history of infertility in trying to conceive as well as endometriosis and cysts. This accounts for the significant muffling (neoplastic area in the pelvic lower body and kidney positions). Her weakness in both the digestive system and liver/gallbladder system caused fluids to not properly transform, leading to damp- heat. Since the Liver is not moving the Qi, the dampness and heat dropped down in the lower Jiao. The Liver brings blood to the uterus and helps move it out. The patient s instability and deficiency in the Liver position accounts for the irregular- amenorrhea of the menses and the neoplastic activity as the stagnant blood just sits, accumulating in the pelvis.
The Lungs rid the colon, open/close the bladder, and assist in the menses. One of the Lung s priorities is to move (disperse and descend) and open the discharge of this blood. The patient diagnosis of Heart Shock is related to: birth where she was a breach baby presentation leading to an emergency C- section. Constitutionally, her mother underwent a significant amount of trauma around the time of the patient s birth, accounting for the Heart Shock, Lung and Heart Qi and Yang deficiency. And, of course, the most recent trauma of the physical injury to her head is understood on its own accord as well as within the backdrop of the foregoing. Acupuncture: Focus: a. LV/GB divergent meridians using deep- superficial- deep, anchoring and stabilizing, descending Liver Yang deficiency rising up. Initial treatment also released stagnation in the GB channel while anchoring. b. Once stabilized, future treatments focused around treating heart shock, boosting the digestive system and continuing to treat the separation of yin/yang in the Liver. Herbs: 1. Hu Po: Anchors the Heart and Liver, calms the Shen, treats heart shock and cools heat. Hu Po also invigorates the blood making it a good choice for traumatic injuries creating blood stasis. 2. Yu Jin and Yuan Zhi: together they open the orifices, treats dampness and heat. Yuan Zhi stabilizes the kidney. Yu Jin invigorates blood and has affinity to the GB. 3. Sha Ren and Mu Xiang: Aids in digesting Hu Po (especially Sha Ren), strengthen the stomach; Mu Xiang moves Liver Qi/Gallbladder and damp heat (both). 4. Ye Jiao Teng: Nourishes the Heart and Liver: Liver blood will nourish Kidney yin, the source of the nervous system. Will also move blood. 5. Ji Xue Teng: Spleen/liver/heart: strengthens the spleen; tonifies and moves blood and strengthens the kidneys. 6. Shu Di Huang: Goes to the Liver and liver blood nourishes kidney blood. It also slightly anchors and stabilizes. 7. Zhi Can Cao: Harmonize the other herbs. Within the formula we are doing the following: a. anchoring and stabilizing the Kidneys and Liver b. treating heart shock: opening the orifices, nourishing and invigorating heart blood, calming the shen c. Moving stagnant qi and damp- heat d. Nourishing liver blood, thereby kidney yin and HT qi e. Treating neoplastic activity by strengthening the liver and digestive system.
Visits: The patient s headaches and dizziness went away during the first treatment. She also got her period the day after the second treatment. Her headaches went away so quickly because of her young age and the specificity of her treatment as revealed by her pulse and subsequent interpretation. Future treatments are designed to address lingering pathology within the immediate interventions as well as to treating and solidifying root issues.