SUBJECTIVE
48-year-old female presents with chief complaint of chronic low back pain, dull and achy in quality, rated 6/10. Worst upon waking, improves with movement and warmth, aggravated by cold and prolonged sitting. Associated symptoms include nocturia 2–3x nightly, bilateral cold lower extremities, decreased libido, and mild fatigue. History of hypothyroidism managed with levothyroxine.
OBJECTIVE
Tongue: Pale, swollen with tooth marks, thin white coat
Pulse: Deep, thin, weak bilaterally at chi position
Palpation: Tenderness at BL 23 bilaterally, mild paraspinal tension L3–L5
ASSESSMENT
Kidney Yang Deficiency with secondary Spleen Qi Deficiency. Presentation consistent with chronic Yang insufficiency failing to warm the lumbar region and lower extremities. Nocturia and decreased libido reflect Kidney Qi failing to consolidate. Tooth-marked tongue and fatigue confirm concurrent Spleen deficiency.
PLAN
Treatment Principle: Warm and tonify Kidney Yang, strengthen Spleen Qi, warm the meridians and alleviate pain
Points: KD 3 (Taixi, 太溪), BL 23 (Shenshu, 肾俞), CV 4 (Guanyuan, 关元), GV 4 (Mingmen, 命门), SP 3 (Taibai, 太白), ST 36 (Zusanli, 足三里)
Herbal Formula: You Gui Wan (右归丸) — Fu Zi (附子) 9g, Rou Gui (肉桂) 6g, Shu Di (熟地) 15g, Shan Yao (山药) 12g, Du Zhong (杜仲) 12g, Tu Si Zi (菟丝子) 12g, Gou Qi Zi (枸杞子) 12g
Dietary Recommendations: Warm cooked foods; emphasize lamb, black beans, walnuts, ginger; avoid cold/raw foods and iced beverages
Lifestyle Recommendations: Keep lumbar region warm; gentle walking daily; avoid prolonged sitting; warm foot soaks before bed
Treatment Frequency: 2x/week x 6 weeks, reassess at visit 12. Expected improvement in pain and nocturia within 4–6 treatments.