Case study with patient with IBS, SHoulder Pain, right knee weakness, fatigue, and eczema
Case study of a 43 year old Male came to the office to receive treatment for Irritable Bowel Syndrome and Diarrhea, which were associated with his anxiety and stress levels. Patient also presented with Shoulder Pain, Fatigue, and Eczema. We used Balance Method Acupuncture to treat this patient.
- Irritable Bowel Syndrome Diarrhea- This was stress induced and would occur after and during anxiety. Patient also states that he had churning on his left mid and lower abdomen.
- Left Shoulder Pain – 1 year ago, he was exercising with a kettlebell and heard a “pop.” Afterwards, he felt pain in the front clavicle region as well as around scapular region and flank area. His range of motion was impaired with lateral flexion and posterior flexion. He currently limits exercise. 6/10 pain.
- Right Knee- 1.5 years ago “popped” and saw an orthopedic surgeon, MRI was clear, “Weakness” overall. 2-3/10 in strength.
- Eczema– Patient has eczema flareups in his inner elbows bilaterally. Red and raised which more itchiness during the night. He will wake up with more irritated flareups because of scratching them at night.
- Fatigue- Patient has been feeling very fatigued since moving to Los Angeles 9 years ago. His energy levels dropped 5 years ago(2014) when he started a family. Mornings are worse for energy and his overall Energy level is 5-6/10. He also has slumps in energy throughout the day. His job is cognitively demanding and stressful.
Dates of treatment:
9/9/19 – initial treatment, Refer above for state of Irritable Bowel Syndrome, Diarrhea, Eczema, and Fatigue. Left shoulder pain was 6/10 with limited flexion. 2-3/10 strength in Right Knee.
9/11/19 – Continued working on symptoms above.
9/13/19- Patient’s stress level increased but his bowel movements were more regulated with less diarrhea within the past 2 days. His left shoulder pain is 3/10 instead of 6/10 in pain.
9/16/19- Patient felt itchier in his eczema flareups. Patient’s bowel movements have regulated and he currently has a bowel movement 1x in the morning.
9/18/19- Patient’s right knee feels stronger 3/10 in strength versus 2-3/10 at the beginning of treatment. Patient’s left shoulder pain is 2-3/10. Patient had some stress induced diarrhea over the past week and this led to incomplete bowel movements after anxiety had passed. Patient’s eczema is less red and inflamed. Currently, his eczema appears drier with light pink coloring.
9/20/2019- Patient currently has complete and formed bowel movements. He has 4/10 strength in his right knee. Left shoulder pain is 6/10. Patient’s eczema is calmer and is less red and irritated. It is slightly pale pink in the inner elbow crease bilateral.
9/23/19-Patient had formed bowel movements on 9/21,22,23/2019. Patient’s left shoulder pain is 5/10. Patient’s right knee strength is 5/10. Patient has some allergic and cold symptoms concentrated in the sinuses.
9/27/19- Patient has had some congestion and very little mucus with his nasal allergies. Patient has had regular and formed bowel movements since the last treatment.
9/30/19- Patient has had regular and consistent bowel movements even during times of stress. Patient’s sinus inflammation and nasal allergies have improved. 5/10 strength in right knee. Patient’s energy levels have improved even with more stress. Patient does not have pain in his left shoulder but does have tension 8/10 in the shoulder. His range of motion is less stiff and more fluid with some limitation.
We will continue treatments 2x/week for the next 2 months.
Written by: Vanessa M. Ho, Licensed Balance Method Acupuncturist at Healing with Zen in Pasadena, California