Acupuncture Treatment of Low back pain
Chief Complaint: Low back pain
Western Diagnosis: Lumbar Spinal Stenosis
Medical History: Patient is a 82 year old male. He has had back pain for over 10 years. Relevant symptoms include achy, radiating sensation down the anterior right thigh and leg. Numbness and tingling in both feet. Major pain is at the right sacral area at the PSIS. It is tender to the touch. He has had back surgery, laminectomy of the L2,3 and 4 vertebrea. Left knee replacement 7 years ago and right hip replacement 15 years ago. he complains of no pain any where else in the body.
Pain scale: 0 through 7-8/10 (10 worse) Description: burning, dull achy when stepping with the right leg. He has no pain when sitting or standing still.
Questioning exam: system review reveals a surprisingly “healthy” man of 82 years old. Sleeps soundly, regular bowel movements, and urinary function. quit smoking 20 years ago. he is without lung problems, digestive anomalies or heart trouble. Bruises easily, patient invariably has purple blotches on forearms and lower legs. Slight edema in the left leg.
Patient is an outgoing, high spirited individual. He exercises five days a week at the gym with weights and cardiovascular therapy. Prior to receiving acupuncture he was not able to gold, now after 8 weekly visits he can golf, but with minor flare ups. He finds this a fair trade off as he loves to gold. He cooks all of his own meals, drinks red wine with dinner and enjoys martinis occasionally.
Pulse exam: Pulse is choppy and wiry, moderate
Tongue exam: tongue is dusky and cracked, with thin white coating with small purple spots on the sides
OM Diagnosis: Kidney weakness with blood stasis in the UB channel.
Treatment Principle: Move blood, tonify kidneys, harmonize liver qi
Point Prescription: Front/supine:P6-L/sp4-R Si3-R/Ub62-L, Ren 4,Sp10,Sp9-R,Ki7-R,Lv3-L.
20 minutes in this position
Back/prone: Ub11,18,23, R-UB52, R Glut medius (ashi). 4 needles surrounding the dragon at PSIS
TDP: Abd. right UB40
Electro acupuncture: Using 2 leads, one + alligator clip on right QL (UB52) and the other + clip on right Gluteus medius ashi point. negative – clips on each two pair of the 4 needles surrounding the dragon, with one negative – clip on right QL(ub52)
Setting at 8-50 hz 20 minutes duration in the prone position.
Herbal Formula: No herbs used
Lifestyle Prescription: Patient already has in place a healthy lifestyle. No recommendations made except to not work out after his treatment.
Results: The results this patient experienced have been very good. He is able to play golf again and be out and about as much as he wants to without worrying about his pain levels. I see him once a month for maintenance visits.
Clinic Name: Caruso’s Center for Acupuncture
clinic address: 36711 American Way suite A
Avon, Ohio 44011
clinic phone number: 440-934-7222
email address: firstname.lastname@example.org