Combination Syndromes

Course: Diagnostics 2 Date: 11/14/07 Class #: 8 No download for this on the Student Portal at this time, but I have exactly made sure I copied down everything from the handout. The bullet points from the handout are the numbered items (1, 2, 3, etc.) The sub components (a, b, ii, etc.) are the things that could cause the numbered items. This sucker came out to 14 pages you might wanna do your charts off of this then just print those plus the case discussion. Combination Syndromes Combinations very important because syndromes usually come in pairs or droves in the clinic. Especially in old people: many disorders over many years, so multiple combinations. On final will give case discussions. Look for the 2 primary organs in the case study that are affected. 1. Qi Xu of Heart and LU 2. Def of both Ht and Sp 3. Blood Xu in both Ht and Lv 4. Yang Xu of both Heart and Kidney 5. Disharmony btwn heart and kidney 6. Qi Def of both LU and Spleen 7. Liver Fire insulting Lung 8. Yin Xu of both Lung and Kidney 9. Yin Xu of both Liver and Kidney 10. Yang Xu of both Spleen and Kidney 11. Disharmony between Liver and Spleen 12. Disharmony between Liver and Stomach All of the above can be grouped into several categories. The first 5 for example are heart related. #6-8 are Lung conditions. 9 and 10 are Kidney, 11 and 12 are Liver related. 1-8 are upper jiao while the rest area lower jiao. Qi Deficiency of both Heart and Lung Upper jiao problem. 1. Palpitation a. Heart 2. Cough, difficult to inhale, worse on exertion a. Cough = Lung b. Worse on exert = Qi Xu 3. Chest tightness a. Phlegm retention b. Qi congestion c. Lung Qi Xu 4. Clear phlegm a. Indicates dampness, perhaps from MJ b. Clear = no heat Page 1 of 14

5. Pallor of face a. Qi Xu b. Yang Xu c. Blood Xu d. Cold 6. Dizziness a. Can be excess, like liver fire, but since no heat, pale tongue, not so b. Blood deficiency 7. Lassitude a. Qi Xu 8. Spontaneous sweating a. Qi Xu b. Yang Xu 9. Tongue: pale body with thin, white coat 10. Pulse: deep, weak or- irregular a. Deep = interior b. Weak = deficiency HT 7, UB 15, LU 9, UB 13 Deficiency of both Heart and Spleen Middle jiao Very specific combination in clinic. This pattern is actually Spleen Qi Xu plus Heart Blood (Xue) Xu. Don t confuse this with something else Ht and Sp related 1. Palpitations a. Heart problems 2. Poor memory a. Blood deficiency 3. Insomnia, Dream Disturbed Sleeping a. Heart Qi Xu b. Heart or Liver Blood Xu i. In many older patients due to blood deficiency difficult to remain asleep 4. Dizziness, vertigo (like last one) a. Deficiency b. Excess 5. Sallow complexion a. Sallow indicates dampness Spleen relation (MJ) b. Add Qi deficiency to this = Spleen Qi Xu 6. Reduced appetite a. Spleen 7. Abdominal distention a. Spleen 8. Loose stool, diarrhea a. Spleen Qi Xu 9. Lassitude a. Qi Xu 10. Bruising a. Spleen Xu cannot keep blood in the vessels Page 2 of 14

b. Heat, causing bleeding out, blood stasis c. Traumatic reasons 11. Scanty and light menses a. Blood deficiency b. Yin deficiency Note about menses: Scanty can be due to Blood or Yin Xu. Yin deficiency will be redder, blood defic will be thinner and lighter in color. Heavy can be due to Blood heat, (spleen) Qi deficiency 12. Tongue: pale with white coat 13. Pulse: Thin, weak HT 7, ST 36, SP 6, SP 3 (LI 10 is more immunologically used to boost wei qi ) BL 17, and other back shu points, but mostly used to tonify/regulate. BL 15 would be better. What is the chief complaint? Often is insomnia. Formula: gui pi tang heart and spleen deficiency. Blood Xu in both Heart and Liver Lower Jiao Heart commands the blood, liver stores the blood. Often see this in anemia patients. Also see this condition in psoriasis patients. This is a chronic pattern, not acute itching type pattern. 1. Palpitations a. Heart 2. Poor memory a. Blood xu 3. Insomnia, DDS (like last one) 4. Dizziness and vertigo (like last one) 5. Pale face a. Qi def b. Yang def c. Blood def d. cold 6. Dry eyes a. Liver yin def 7. Blurred vision a. Liver yin def advanced to liver blood deficiency 8. Numb limbs a. Anemia and malnutrition qi/blood xu can cause this b. Blood xu 9. Tremors Very specific manifestation. a. Liver wind. i. Different kinds of wind and vertigo belong to liver. Page 3 of 14

ii. Blood deficiency generates wind. b. Another symptom of wind: itching. Rashes. c. Treatment: tonify the blood. 10. Little menses a. Blood xu b. Yin xu (comb with night sweat, five palm heat, thirst, dark red tongue with little coat) 11. Tongue: pale with white coat 12. Pulse: thin and weak Neijing says tonify the blood. To treat wind ahead of time, treat blood. UB 15, UB 18, LIV 8, HT 7 Yang Xu of both Heart and Kidney Lower jiao Tricky pattern. Ht and Kidney relationship also has another combination syndrome (Heart and Kidney Disharmony). Look for cold signs, swollen face, chest tightness with a coldness there. Many chronic heart failure patients have this. Always want something covering their chests. 1. Palpitation a. Heart 2. Pale face a. Qi xu b. Blood xu c. Yang xu d. Cold 3. Aversion to cold, cold limbs a. Can be due to Yang xu b. Could also be due to extreme anger causing Qi congestion 4. Sleepy a. Generally is due to Heart Qi b. Can be due to Spleen qi deficiency energy being used for digestion after a big meal. 5. Edema in face/limbs, especially on lower legs. a. Kidney yang related when on lower extremeties. Water cannot be steamed away, so will float, gather like a swamp. b. Edema on all 4 limbs, more likely due to Spleen. c. Edema that doesn t stay depressed when you mash on it is Qi edema. 6. Cold, soreness/weakness of lumbar and knee joints a. Definitely Kidney coldness, in this case yang def. 7. Pale nails and lips a. Blood Xu b. Qi Xu c. Yang Xu 8. Early morning diarrhea a. Typical Kidney Yang Xu 9. Tongue: pale w/slippery coat Page 4 of 14

a. Yang Xu b. Qi Xu c. With water retention 10. Pulse: deep, feeble, slow a. Deep = interior chronic/longterm b. Feeble = deficient c. Slow = cold Can use moxa or warm needling for these patients. DU 4, HT 7. Disharmony of Heart and Kidney There are two basic relationships between heart and kidney: heart/kidney yang deficiency heart/kidney yin deficiency. Yin deficiency of heart/kid is called Disharmony of Heart and Kidney Unique relationship between heart and kidney this is a heart and fire relationship. These must be balanced or the water will overpower and extinguish the fire or the fire will boil the water away. If water is too little, cannot nourish the heart, the fire gets too strong and burns the kidney, burns away more water. This is a bad scene, man. The basic problem: yin deficiency 1. Palpitations a. Heart 2. Insomnia a. Blood deficiency 3. Restlessness, irritability a. Some liver fire, but related to the heart fire 4. Poor memory a. Heart yin/blood xu 5. Dizziness, vertigo a. Lower jiao has yin def, then yang upward 6. Tinnitus a. Kidney yin def 7. Dry throat a. Kidney channel goes thru back of throat 8. Tidal fever a. Yin def 9. night sweating a. Yin def 10. Soreness of waist/lumbar a. Kidney 11. Spermatorrhea in dreams a. Kidney def 12. Tongue: red with little coat 13. Pulse: thin/rapid Tonify Kid 3, reduce Heart 8. Page 5 of 14

Qi Deficiency of Lung and Spleen 1. Chronic, constant cough with profuse clear phlegm a. Cough = lung b. Phlegm = spleen c. Chronic = deficient d. Clear = no heat 2. SOB a. Lung deficiency 3. Poor appetite a. Spleen 4. Abdominal distension a. Spleen 5. Loose stools, diarrhea a. Spleen Qi def UB 13 and UB 20 Liver fire insulting Lung First is emotional problem, then fire/heat 1. Burning pain or distension in costal/hypochon area a. Liver 2. Quick temper, irritability a. Liver, heat 3. Restlessness a. Liver Fire/wood over long time affects Heart/Shen. This is a Mother/Son relationship 4. Dizziness a. Wind due to excessive heat. 5. Red eyes a. Liver fire liver opens to the eyes b. If the sclera is red, is liver fire affecting/insulting the lung 6. Bitter taste in mouth a. Liver fire b. Stomach fire c. Gallbladder fire 7. Violent intermittent cough a. Violent = Excessive lung problem 8. Sticky little yellow phlegm, spitting blood a. Sticky, little, yellow = heat b. Spitting blood = heat c. Liver insulting lung 9. Hot sensation in chest 10. Tongue: red with thin yellow coat a. heat 11. Pulse: wiry, rapid a. Wiry = liver b. Rapid = heat Page 6 of 14

Treatment: LIV 2 (reduce), LU 5 (reduce) Yin Xu of both Lung and Kidney 1. Cough plus little sputum or bloody sputum a. Little = deficient b. Cough = lung c. Bloody sputum = little/defic heat 2. Dry mouth: sore/dry throat a. Dry = yin or body fluid def b. Sore throat = lung, kidney meridian 3. Hoarse voice a. Lung yin deficiency 4. Losing weight, emaciated a. Yin deficiency sign 5. Soreness/weakness of lumbar and knee joints a. Kidney deficiency 6. Tidal fever, malar flush a. Yin deficiency 7. Night sweats a. Yin xu 8. Nocturnal emission a. Kidney yin xu 9. Less menses a. Yin def 10. Tongue: red with little coat a. Red = heat b. Little coat = deficient 11. Pulse: thin and rapid. a. Thin = deficient b. Rapid = heat Patient also may complain of tinnitus kidney yin def a high pitch. UB 13, UB 23, KID 3, UB 43 Page 7 of 14

Yin Xu of both Liver and Kidney 1. Dizziness, vertigo a. Wind. Wind can be caused by blood deficiency, heat excess, or yin deficiency (def heat). (Greg s explanation: too much merry-go-round) 2. Tinnitus a. Kidney yin deficiency 3. Hypochondriac dull pain a. Hypochondriac = liver b. Dull = deficient 4. Poor memory a. Heart blood deficiency if short term b. Kidney deficiency if long term memory 5. Insomnia, DDS a. Heart blood related now won t that just throw you off! On exam: just pick 2 symptoms don t be confused by the red herring b. This can also be liver related, as liver stores the blood. If it cannot do that, the Shen will wander around messing stuff up 6. Dry throat/mouth/eye a. Liver 7. Loosing weight, emaciation a. Yin deficiency 8. Soreness/weakness of lumbar/knee joints a. Kidney 9. malar flush, night sweats, 5 palm heat a. Yin def 10. Nocturnal emission a. Kidney yin def 11. Scanty menses flow a. Yin def, probably kidney, maybe liver 12. Tongue: red with little coat a. Red = heat b. Little = deficiency 13. Pulse: thin and rapid a. Thin = deficiency b. Rapid = heat KID 3, LIV 3 Compare this to the Heart/Kidney disharmony! Please exactly make sure of the differences. No palpitations here, but add the dry eyes and hypochon pain. Page 8 of 14

Yang Xu of both Spleen and Kidney 1. Pallor of face a. Yang def/qi def/blood def, cold 2. Poor appetite a. Qi def, prob spleen 3. Aversion to cold, cold limbs a. Cold limbs = spleen yang def 4. Cold, soreness/weakness of lumbar and knee joints a. Kidney def 5. Loose stools or diarrhea at dawn; chronic diarrhea a. At dawn = kidney yang deficiency b. Chronic = long term 6. Incontinence of urine a. Kidney qi or yang Xu 7. Facial puffiness and edema of limbs a. Edema of limbs = spleen With edema, draw an imaginary line at the waist. If above: Yang shui or yang edema. LU, SP If below: Yin shui or yin edema. SP, KID 8. Tongue: pale, swollen with slippery white coat a. Spleen qi def spleen yang deficiency spleen/kidney yang def 9. Pulse: deep, feeble, slow a. Deep = interior b. Feeble = deficient c. Slow = cold Moxa: sp 6, sp 9, du 4 Page 9 of 14

Group the following 2 together Disharmony between Liver and Spleen The word disharmony in TCM has special meaning. Liver is overacting on Spleen. Usually starts with 1. Distention/Fullness and pain in the costal/hypochondriac area a. Liver 2. Sighing a. Liv qi stag 3. Poor appetite a. Sp qi def 4. Abdominal distension a. Sp qi def 5. Depression, irritability a. Liver fire related 6. Loose stools, constipation a. Spleen qi def 7. Tongue: white or greasy coating 8. Pulse: Wiry a. liver Disharmony between Liver and Stomach Could be heat: liver qi stag transformed to fire, overacting on stomach Could be due to cold retained inside then affecting liver and stomach. 1. Distension/fullness and pain in costal/hypochondriac area 2. Belching, hiccup, acid reflux a. Stomach qi can t go down, rebelling upward b. This patient could also have constipation 3. Irritability 4. Tongue: red body, thin yellow coat 5. Pulse: wiry and rapid. 4 gates, spleen 3, stomach 36 Page 10 of 14

Case Discussions There are 4 of these. I wrote the case down as Dr. Luo gave it to us on a handout so you have a chance to disect it and decide which of the combination patterns discussed today fit the description. If you look at the last pages you will see the discussion we had about it along with the correct diagnosis in blue. Note: A complete OM case discussion includes the following: 1. Diagnosis of chinese or western med 2. Differential diagnosis 3. Location of the disease (whether in yin, yang, organs, meridians) 4. Property of the disease (whether deficiency, excess or both) 5. The principles of treatment 6. The acupoints for the case Case 1 This is a very practical example and will be very similar to what you see on the boards. Zhang, 42 y.o. female Chief complaint: cough for 10 days Patient reports: Has a cough for 10 days with little sputum that is sticky and yellow. It was severe at the beginning, but alleviated now after taking meds. Currently it is a constant, strong cough and her voice is disturbed. She coughs a lot in the morning, but it s better in the daytime. She mentioned that she quarrelled with her family 2 weeks ago. Afterwards, she started having headaches on the vertex, irritability, red and swollen sensation in her eyes, bitter sensation in her mouth, stuffiness in her chest, burning pain in hypochondriac area occasionally. Overall, she feels hot. Physical assessment: Comprehensive heavy sensation in the chest, heavy breath. Tongue is red in the front and sides of body with thin yellow coating Pulse is wiry and rapid. Case 2 Wang, 46 y.o. male Chief complaint: palpitation for 4 years and poor appetite after half a year Patient reports: Felt the palpitation sensation for 4 years. He s got poor memory and bad concentration. Sometimes it is very difficult for him to focus on his work. He has been to a doc, but no positive or obvious findings to the tests. He doesn t have a good appetite and suffers from gas and bloating after meals. Occasionally he has diarrhea and easily gets bruised. He sleeps badly even when he s exhausted. Has dream disturbed sleep and wakes up tired. Physical assessment: Page 11 of 14

Pale complexion, soft muscles, no positive physiological reactions, but tends to react slowly. Tongue is pale and swollen with teethmarks, white coat. Pulse is thin and weak Case 3 Zhu, 70 y.o. male Chief complaint: heart palpitation and diarrhea for 10 years Patient reports: Palpitations for 10 years. He has been to doc and got EKGs, but everything looks normal even with 24 hour monitoring. He feels confused, but didn t know what to do about the situation. He heard about acupuncture and decided to give it a try. Physical assessment: BP is 140/75. Pulse is 76bpm, breath rate is normal. Appetite is good. He jogs regularly. He as spontaneous sweating. Sometimes he feels tired and it gets worse with exertion. He usually has a bowel movement early in the morning which varies from loose to watery in nature. He mentioned that he felt cold in the chest and lower back. His urine is clear and usually copious in amount. Occasionally he dribbles (no, not basketball) due to his enlarged prostate. He mentioned he has edema in both lower legs. Tongue: purplish, slippery white coat Pulse: feeble, slow, deep Case 4 Li, 55 y.o. male Chief complaint: Fatigue for 3 years Patient reports: He was very energetic and did mountain bike training for a while. He trained very hard 3 years ago for a national competition. After training very hard he began to feel weak. He tried to remedy this with good rests, sleeping, good foods, but to no positive result. His appetite is poor and he feels tired after he eats. He also notices he feels very full in the epigastrium after eating, even if he eats little meals. His bowels are loose, but no diarrhea. He also coughs sometimes, but it s not bad. He only coughs when he feels weak. The cough produces a profuse amount of sputum. His voice is low and he is short of breath. Physical assessment: Tongue: pale with teethmarks and a thin white coat Pulse: weak. Page 12 of 14

Case 1 Class Discussion and Diagnosis of Combination Symptom Patient report: Cough = lung. Little suputum, sticky, yellow = heat sign Severe cough both at onset and current = Lung excess Coughing in the morning = lung qi is disturbed by her change of physical position when she gets up out of bed. Quarrelled with her family 2 weeks ago: emotional turmoil fire in liver. o Afterwards got the vertex headache, irritability, red/swollen eyes, bitter sensation in the mouth, burning pain in the hypochondriac area = Liver fire o Also note that she mentioned chest stuffiness in this litany = fire going up to the Lung. General hot feeling = heat Physical assessment Comprehensive heavy sensation in the chest = lung Heavy breath (breathing hard) = Lung excess Tongue, red on front and sides, thin yellow coating o Red tongue on front part = heart or lung heat o Red tongue on sides of tongue body = liver or gallbladder heat o Thin yellow coating on tongue = heat Pulse: wiry and rapid o Wiry = liver o Rapid = heat The lowdown: Liver Fire attacking/insulting Lung Case 2 Class Discussion and Diagnosis of Combination Symptom Patient report: Palpitations for 4 years = heart and chronic Poor appetite for ½ year = spleen deficiency (because it s been going on long enough to be chronivc) Poor memory, bad concentration = heart blood deficiency Difficult to focus = heart blood def Went to the doc and no conclusive results = damn AMA! Doesn t have a good appetite = spleen qi xu (deficiency) Easily bruised = spleen qi deficiency Sleeps badly = heart blood xu Vivid-dreaming during sleep = heart blood is disturbed either by heat or by deficiency Wakes tired = spleen qi deficiency Physical assessment: Pale complexion = heart blood xu Soft muscle = spleen qi defic Pale swollen tongue with teeth marks = spleen qi deficiency with water retention White tongue coat = no heat Thin weak pulse = deficiency Page 13 of 14

The Scoop: Deficiency of both Heart and Spleen Case 3 Class Discussion and Diagnosis of Combination Symptom Chief Complaint/Patient report Palpitation = heart Diarrhea for 10 years = spleen or kidney, chronic problem Appetite is fine = spleen is probably fine after all Spontaneous sweating = qi or yang xu Tired feeling, worse with exertion = Qi deficiency Bowel movements early morning loose to watery= Kidney yang deficiency Cold in the chest = heart or lung cold (excess or deficient), probably yang deficient Cold in the lower back = kidney cold probably kidney yang Urine is clear, copious = excess or deficient cold Dribbling of urine = kidney deficiency or kidney qi deficiency Edema, both legs = kidney yang deficiency Tongue o Purple = stasis o Slippery, white coat = damp or water retention without heat Pulse o Deep = interior/chronic o Feeble = deficient o Slow = cold And in summary: Yang deficiencyt of both Heart and Kid-uh-ney (Wu pronunciation pattern) Case 4 Class Discussion and Diagnosis of Combination Symptom Chief complaint/patient report/physical assessment Fatigue = qi deficient, probably spleen Tired after training very hard = the dude burned away some Qi! All things in moderation, grasshopper! Weakness after training = qi deficiency Poor appetite and tired after meals= spleen qi defic Epigastric fullness after any meal = spleen Bowel is loose, not diarrhic = spleen or kidney yang problems Coughs, though not bad, when he feels very weak = Lung deficiency Cough with profuse sputum = phlegm retention, no heat Low voice, shortness of breath = lung qi deficiency Tongue o Pale with teethmarks = qi deficiency (prob spleen) with water retention o Thin, white coat = thin is deficient, white is no heat Pulse o Weak = deficiency Add it all up and whaddaya get? Qi deficiency of both Spleen and Lung Page 14 of 14