Patients Name: Ms. H. M. Age: 45 years old
Date of visit: 26-06-2018
Chief complaint: The foot sag has taken place for 43 years. accompanied with swelling of the ankle
History of present illness: When the patient was 18 months old, she fallen dowen and injured. At the time, the left-brain injured, the right lower limb is weak, right ankle dorsiflexion can not reach normal position. Even have done three operations and multiple physical therapy, now the lateral ankle joint is still swelling, dorsiflexion limit, powerless.
Physical examination: This patient’s ankle and foot disease involves the meridians of the gallbladder and the bladder. What the right knee lift up is weaker than the left side, and what the right toe lift up is obviously weaker than the left side.
Pulse diagnose: The pulse of left side is weaker.
Mechanism of disease: Qi deficiency: Meridian dysfunction
Therapy：Acupuncture on Tong Li, Yu Ji, both right side.
Result: What the right foot palm dorsiflexion, immediately is able to return to normal position.
Second visit: 02-07-2018:
The swelling of the right ankle is basically disappear, what the right foot palm dorsiflexion, can reaches the normal position.
Consolidation treatment, acupuncture points: Yu Ji, Tong li (right side), both side of Tai Xi.