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Patient Intake Record
Case Report
Patient's Name: Perez, B
Gender: Female
Date of Birth: 06/XX/1985
Occupation: Registered Nurse
Marital Status: Single
Private
Phone [HIDDEN] Private
Chief Complaint: Bell's palsy
History of Present Illness:
The patient states she first felt numbness on her tongue 10 days ago. When she woke up in the morning and was cleaning her teeth, the water was dripping from her mouth. Her right eye was not able to close completely, and she felt numbness on the right side of her face.
Medical History:
The patient consulted with her doctor who confirmed the diagnosis as Bell's palsy; her doctor prescribed prednisone for 14 days. The patient came to see me on 8/29/2013. The patient states she has pain and numbness on the right side of her face, drooling, loss of the ability to taste, and her right eye cannot fully open or close and has excessive tearing.
Personal History:
Menstrual History: She is taking birth control pills.
LMP: N/A
Obstetrical History: None
Smoking/Addiction/Alcohol History: None
Family History: Her mother had Bell's palsy.
Current Medications and Herbs: She is taking Prednisone (Corticosteroids, Anti-inflammatory).
Review of Systems:
Energy: Tired
Sleep: Ok
Mood: Since she is a nurse and continues to work with this condition, it causes her emotional distress because of its characteristic drooping appearance around the eye and mouth, thus adversely effecting self-esteem and work experience.
Appetite/Thirst: Normal appetite. No thirst.
Digestion: Good
Bowels: 1/day, little loose.
Urine: o.k.
(O) Examination
HEENT: Pain and paralysis on right side of face.
Drooling mouth and loss of ability to taste.
Eye cannot fully close on the right...
Wiry
3. Deep
Right:
1 Slippery
2. Slippery
3. Deep
Tongue: Pink
Coat: white fur
Complexion: Slightly dusky under eyes.
(A) Diagnoses of Diseases and Patterns
Pattern/Syndrome Differentiation Analysis:
The patient is a young, and healthy female nurse, besides the Bell's palsy. She works in rotating shifts and needs to work through the night (12-hours shifts) at the childbirth center. This rotating shift is similar to changing time zones several times a month, without time to adapt or recover; the patient states she did not have enough rest before going to work.
According to T. Deng [1], a lifestyle of consuming incorrect foods, overwork, stress, and indulgence where Qi is consumed without replenishment builds the vacuity pattern. External wind takes advantage of this vacuity to enter her body and attack the sinews and vessels in that area of her face. This results in Qi and blood stagnation causing the inability of flesh to relax or contract. Because the patient was overworked, her Qi weakened [2].
The Qi deficiency can cause a failure in transportation, leading to dampness that further failed to transform and caused turbid phlegm stagnation within the body. External wind invading the collaterals disturbed internal phlegm, which travelled through the face causing stagnation in the…
References
[1] Deng, T (1999)."Abdominal pain," in Practical Diagnosis in Traditional Chinese Medicine, K. Ergil, Ed: Churchill Livingstone, London, UK, 1999, pg. 464 -- 472.
[2] Wolfe, H (2003). "Joining Needling for Facial Paralysis." Blue Poppy Press. <http://www.bluepoppy.com> Accessed 10 June 2005.
[3] Bell's Facial Paralysis, Clinic of Traditional Chinese Medicine, Vol. II (1990), Practical English Chinese Library of Traditional Chinese Medicine. Shanghai College of Traditional Chinese Medicine, pg. 964.
[4] Suk, YM (2008). Understanding the Jin Gui Yao Lue, A Practical Textbook, Peoples' Medical Publishing House, pg. 110.
[5] NINDS (April 2003), "Bell's Palsy Fact Sheet," NIH Publication No. 03-5114, http://www.ninds.nih.gov/disorders/bells/detail_bells.htm
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