CASE STUDY 만성요통
S: SUBJECTIVE
CC: Chronic LBP
Associate Symptoms:
LEFT GROIN PAIN
LUMBOSACRAL SPONDYLOSIS
LUMBER RADICULOPATHY
History of present illness:
The patient has chronic Low Back pain for 2 years without reason.
The patient scheduled the back surgery. However, she did not get surgery due to hypertension.
Pain VAS : 3/10 – 7/10
Chronic pain for 2-3 Years / 2014 Last year got worse. Pain started, 2014 DJD 08/03/2026 DJD
Constant pain VAS 7/10 Aggravation/Alleviating Factors: Any Activities / Rest
X-rays, MRIs findings: Bulging disc
Past Surgical History:
Allergies, Arthritis, Brest Lump, Convulsions / Seizures, diarrhea / Constipation, Fainting or Dizziness, Headache, Heartburn or Indigestion, High Blood Pressure, Hospitalization /Surgical Procedures: Gall Bladder Remove, Thyroid Disease
Family History
Cancer – Mother / Father
Hypertension: Grand Mother
Social History:
No smoking/ Drinking
Medication:
Losartan 100 mg
Atenolol 50 mg
Keppra (Levetiracetam)
Levothyroxine
Carafate
Lipitor
Imitrex
Flonase (Fluticasone Propionate Nasal Spray)
Protonix
Chlorthalidone
Neurontin
Ultram Pain Pill 50 mg.
Aspirin 81mg
TYLENOL® For Arthritis Pain 325 mg.
Under the care of a physician:
High Blood Pressure, Seizers, Gastroparesis
O: OBJECTIVE FINDINGS
Palpitation, tenderness, or pain: severe (x)
ROM: (NL/ROM, with pain/without pain) Poor ROM
Pain VAS 7/10
BP: 150/70
OSWESTRY DISABLIITY SCORE : 28/50 56%
Tongue DX: Tongue Body Red color
Tongue Coating: Scanty T/C
Pulse DX: Left Cun/Guan/Chi: Wiry Right Cun/Guan/Chi: Wiry
A: Assessment
Western Diagnosis / CPT Code: G89.29
CHRONIC LOW BACK PAIN – PRIMARY
LEFT GROIN PAIN
LUMBOSACRAL SPONDYLOSIS
LUMBER RADICULOPATHY
P: PLAN
침굵기: 3호침(0.25mm)
침길이 : 30mm
보사법: 영수보사
유침시간: 1시간
치료경과
치료기간 : 11/22/2016 – 04/22/2017 환자 사위가 소방관으로 은퇴후 원래 고향이던 워싱턴으로 이전 전까지 래원
재진율이 높을수록 치료율이 높음
총치료 회수: 주 2-3회 총 19회
미용침으로 연결하여 치료
침구치료로 개선된 증상들:
요통
변비
안구건조
복진결과
소변약함
냄새맡는것
다리경련
양 손가락 통증
Acid Reflex
환자 최종혈압: 초진혈압 150/70 에서 130/74
환자를 통해 치료한 환자 총5명(Patient’s Referral): 환자 따님, 아버님, 환자 남편, 환자 이웃(환자이웃, 환자 아들)
근골격계 치료가 잘되면 내과질환, 비만치료, 미용치료까지 연결시켜서 치료가능
환자의 선물
March 2017 Dr.Kim You are a miracle worker! We thank you for all of your wonderful magic needles. You have a gift for you craft. Thank you!