500 Sheppard Ave. E. Unit 205, Toronto Ontario
647-296-3226
40 years old and 11 months. First visit date is March 14 th,
2018.
Her main
complaint is two miscarriages which happened in Dec.2016 and Nov.2017
respectively. She has had multiple fibroids since 2012. And the
ultrasound in March 22th, 2018 shows she has polyps in the uterus. Aversion to cold in
general. Frequent urination and urinary incontinence since the first
miscarriage. Stool has hard head and
soft end.
Menstrual history: once /month,
25 days per cycle before second miscarriage, after second miscarriage is 30
days per cycle. 5-6 days per cycle, normal amount, red color, has small amount of
blood clots. Recent period was March 7-12.
Tongue: reddish
tongue, thick tongue body with teeth marks on sides, white coating. Sublingual
veins have prominent branches, purple colour.
Pulse: Left hand-
deep with cùn weak. Right hand- deep, weak, taut and uneven
Diagnosis: Deficiency of spleen and kidney, blood
stagnation and blood deficiency
Treatment
method: Use herbs and acupuncture to promote spleen and kidney, disperse
stasis to build up blood level and promote blood flow. Also, the patient should
not try to get pregnant for 6 months.
Process and
Result: After 4 sessions of acupuncture and herbs, in the fifth visit on March
29th, frequency of urination dramatically decrease, and no more
incontinence. the seventh visit is on April 5th, which was the fourth
day of her period, she told me that there was a lot of blood clots this time (it
is a sign that her blood stasis is dissipating). On April 11th, she went
to surgery of remove polyps, however the doctor told her they did not find any
polyps. It was some tissue from her second miscarriage, so the doctor removed
that. From the day of surgery to April 19, she reported a small amount of
bleeding. On April 20th, I gave her herbs to clean the stasis. From April
24-26, her period was heavy with a lot of dark colored blood with blood clots.
After that, bleeding stopped. She had period on May 18-21 and June 12-17, both
periods were red in colour, regular amount with a small amount of blood clots. On
July 6th, report showed she was four weeks pregnant. However, she
showed miscarriage symptoms again, and there was small amount of brownish
liquid that came out. Right away, I used acupuncture and herbs to prevent her
from having another miscarriage. She even had red blood came out one day when
she worked on her feet a whole day. I modified the herbal formula for her, and
she took those herbs until 16 weeks into her pregnancy. Her expected date is next month, February 2019.
Congratulations!
初诊日期:2018-03-14
年龄:40岁11月
主诉:2016年12 月孕5周和2017年11 月 孕4周自然流产两次。自2012年起查出有子宫肌瘤。2018年2 月的报告显示三个肌瘤,直径分别为2.5,2.9,3.8。报告还显示有子宫息肉。平时怕冷,第一次流产后开始出现尿频现象和憋不住尿感觉。大便头硬尾软。
月经史:1次/月,以前是25天一个周期,自从第二次流产后是30天一个周期。5-6天/次,量中,色红。少量血块。末次月经: 3月7-12 号。
舌诊:舌质淡红,舌体厚。边有齿痕,苔白。舌下络脉多,色紫。
脉象:左手沉,左寸弱 右手沉弱,弦,不均匀
诊断:血瘀血虚,脾肾不足
治疗:祛瘀温经,健脾益肾。针灸中药并施。医嘱病人避孕半年后才尝试怀孕。
结果: 经过4次治疗,3月29日第五诊时告知尿频大减,憋不住尿的感觉消失。
2018年4 月5日第7次就诊时适逢月经第4天,告知本次月经比以前血块多。此是淤血外排的好现象。
4月11日去做手术切除息肉,医生告知没有发现息肉,但发现有第二次流产时遗留的少量胚胎组织,予以手术清除。术后4月11-19有少量血排出。4月20号来诊所就诊给与生化汤加红花,刘寄奴,益母草祛瘀生新。药后24-26号排出较多黑色血,夹杂大量血块。
继续中药加针灸治疗。5月周期是18-21号;6月经期在12-17号,两次月经均色红,量正常,少量血块,2018年7月6日证实怀孕4周+。刚怀孕,又出现了流产现象,看到一点棕色液体排出。马上用针灸加中药保胎,期间她因为工作几乎连续站立1天而出现出血较多现象。调整中药继续安胎致16周。
她的预产期是今年2月,恭喜她!
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