Female, 17 years old
Reason for consultation
Recurrent urinary tract infections every 2 to 3 months for the past year.
Clinical history
- Migraines since age 12. Photophobia for the past year.
- Tension in neck, trapezius and shoulders.
- High stress due to self-imposed academic pressure.
- Wakes up with dry mouth and a strange taste.
- Sleeps but does not rest, wakes up around 3 am and then has difficulty falling back asleep.
- Constipation, gas, abdominal bloating.
- Nasal mucus in the morning.
- Painful and heavy menstrual period, regular (28 days) but lasting up to 2 weeks; for the past year she was prescribed contraceptives and now menstruates for 4–5 days, very heavy with pain and clots.
Pulse
- Right cun and guan: convex, deep and without resistance.
- Right chi: Amorphous, deep and compressed.
- Left cun: Convex, medial and without resistance.
- Left guan: wiry and without resistance, slightly thin.
- Left chi: Thin, deep and without resistance.
Diagnosis
- Empty-Heat of Heart, Liver and Kidney
- Yin-Blood deficiency
- Deficiency of Lung-Qi
- Damp-Heat in the Lower Burner
Therapeutic principles
- Resolve Heat.
- Tonify general Yin.
- Drain Dampness.