Medical Dialogue

医学会话

Discussion on Eight-Principle Pattern Differentiation
讨论八纲辨证

Daniel Zhang is a clinical supervisor at Blue Ocean Acupuncture College in Australia. He is counseling with a first year intern, Lisa Kawasaki about a patient.

dr. zhang:	Hi, Lisa. Review your patient today.
lisa:	Hello, Dr. Zhang. My patient is Mr. W in exam room 12. He has type 2 diabetes and HIV. He first visited the clinic one week ago for an herbal consultation regarding a three week-old flu he was struggling with.
dr. zhang:	How does he feel today?
lisa:	Today he reports better energy and improved appetite. The cough is notably alleviated, and he has slept through the night. He also reports that since completing the herbal formula the frequency and duration of his bouts of anger have lessened and he would like to refill his prescription.
dr. zhang:	What are his clinical manifestations?
lisa:	His pulse is thready and slow; overall it is at the deepest level. His tongue is red as a fresh peeled grape. He also reports chronic intermittent numbness and pain in his right foot, which he did not mention in his previous interview.
dr. zhang:	What do you propose?
lisa:	Where do we start? The progressive neuropathy of both legs from the diabetes, or the HIV? Both diseases are consuming his yin. And how are his HIV meds influencing his signs and symptoms, including his main complaint?
dr. zhang:	Remember, we are not treating a disease. Our aim is to differentiate his pattern presentation and to correct those imbalances so that his body can carry on. Now what do you want to do for Mr. W?
lisa:	I want to help him with his neuropathy. What can we do about the pain that he has in his legs now? Do we just address the channels to treat the pain in his foot?
dr. zhang:	Recall for me the eight principles.
lisa:	They are the eight basic categories of syndromes. They are interconnected and inseparable. They are yin and yang, exterior and interior, cold and heat, deficiency and excess.
dr. zhang:	Now we review Mr. W. through that lens. Your treatment strategy is not to address his neuropathic pain exactly. It is to correct the imbalance that lead to his present illness. Look at Mr. W's clinical presentations in a general way. Let's start from the top. Is his complaint yin or yang?
lisa:	Yang. His chronic condition has damaged his yin and his body's normal qi flow is challenged. We observe this in his reported bouts of anger and depression. We see it in his red eyes and sense it when he talks.
dr. zhang:	Exterior or interior?
lisa:	That one is tricky. It appears to be rooted in the interior, but the signs and symptoms are exterior, affecting the lower extremities, in the muscle and the superficial portions of the meridians and collaterals.
dr. zhang:	Is his presentation hot or cold?
lisa:	He feels hot to the touch.
dr. zhang:	Does he say that he feels hot?
lisa:	Just before taking the formula he had sweating through his T-shirts regularly at night. He has a sense of heat radiating from his head and neck. He had experienced this months prior to his herbal prescription. But since taking it, he has had no more strong night sweats. He does say that he feels cold inside and has intermittent abdominal pains with loose stools. The pain in his feet he describes is burning.
dr. zhang:	Just as the exterior and interior signs are overlapping with Mr. W's presentation, there are also cold and heat, and excess and deficient complex.
lisa:	The presence of both cold and heat has led to a disharmony between the yin and yang. Heat above, cold below.
dr. zhang:	Could this involve false phenomenon?
lisa:	True. Cold with false heat on the exterior. The burning sensation he describes in his feet is real heat.
dr. zhang:	Yes, but could that excess he describes result from a deficiency?
lisa:	Yes, the deficiency of his liver and kidney yin. I felt that in his pulse.
dr. zhang:	Do you remember from chapter twenty-eight of the Su Wen, what causes excess and what causes deficiency?
lisa:	Excess is heat and deficiency is cold?
dr. zhang:	Excess is caused by the hyperactivity of the defensive qi. Deficiency is caused by the consumption of qi or the insufficiency of defensive qi.
lisa:	OK, so Mr. W's immune system was already compromised prior to the lingering flu symptoms that brought him into the clinic a week ago. He did not have enough defensive qi to kick out the pathogen entirely, and the antibiotics may have pushed the pathogen into a deep latent state.
dr. zhang:	Is that what you found in Mr. W's pulse?
lisa:	Well, not exactly.
dr. zhang:	The pulse was slow.
lisa:	That can mean cold.
dr. zhang:	That does mean cold. And in this case with Mr. W, we must accurately differentiate between the false and true phenomena. It is important to determine which predominates and which is more urgent.
lisa:	Mr. W does present with signs of both heat and cold. But was the cold already there or did it result from the herbal formula?
dr. zhang:	Let's look at the formula. Wow. They combined Liu Wei Di Huang Wan with Ren Shen Bai Du San. Interesting. His cough is better. His energy and appetite are improving. He even feels less agitated. So we will not refill his prescription as it is. He has overcome the pathogen and now we must continue to nourish him and warm his yang. Jin Gui Shen Qi Wan will be good for him.
lisa:	And what about the pain in his feet?
dr. zhang:	The formula will warm and tonify his yang and remove any blood stasis. The numbness and tingling should get better as a result. Also, apply a mild warm moxa to his points shenshu (BL23), pishu (BL20), ganshu (BL18), zusanli (ST36) and yongquan (KI1). He will leave feeling better.
lisa:	Thank you, doctor.