TCM Case Record – Generalized Edema
Patient Information:
Name: James
Gender: Male | Age: 45 | Occupation: Office Manager
Chief Complaint:
Generalized edema for three months, mainly in lower limbs, face, and hands. Worse in the evening and after sitting. Additional symptoms: fatigue, heaviness, occasional shortness of breath.
History & Lifestyle:
Gradual onset, worsening over time.
Slightly reduced urination (dark yellow), sluggish bowel movements.
Poor sleep, waking frequently.
Mild hypertension (controlled), no kidney/heart disease.
Sedentary job, high intake of processed/salty foods, stress.
TCM Diagnosis:
Pattern: Spleen Qi Deficiency with Damp Retention
Tongue: Pale, swollen, teeth marks, white greasy coating
Pulse: Deep, weak, slippery
Treatment Plan:
1. Acupuncture: SP9, ST36, REN12, UB20, UB22, KD7 – Strengthen spleen, resolve dampness.
2. Herbs: Modified Wu Ling San (Fu Ling, Bai Zhu, Ze Xie, Sheng Jiang, Dang Shen).
3. Diet & Lifestyle: Warm, digestible foods; reduce salt/processed foods; mild exercise (Tai Chi, walking); stress management.
Prognosis & Follow-up:
Weekly acupuncture for a month, reassess.
Adjust herbs as needed.
Improvement in 4–6 weeks.
