A 7 year old spayed female DSH had presented to another clinic for a rabies vaccine in February 2014. Shortly thereafter she developed a bilateral otitis with a purulent discharge. She was treated with antibiotics for 2 weeks. The ear discharge stopped, but she developed a severe head tilt and ataxia. She fell down when she jumped. She was then treated with silica, which was no help. Blood work and radiographs were non remarkable. Since March there was no improvement with the head tilt and ataxia. On July 26, 2014 she came to my clinic.
WESTERN EXAM July 26, 2014:
She had a prominent head tilt with a 60 degree rotation with the right side down. She was ataxic at the walk. Her mucous membranes were pink and the heart and lungs auscultated normally. The optic exam was normal and the ear drums were within normal limits. Abdominal palpation was non remarkable. There were no proprioceptive deficits. The retina and optic disc appeared to be normal. There was a lateral and downward strabismus to the left eye.
TCVM EXAM July 26, 2014:
History: The major complaint was ataxia. In Chinese Medicine, ataxia would be considered Wind which is associated with the Liver element. She bossed the other cats around. Her personality is Wood which is part of the Liver element. She was not on medications and there was no change in the disease course for the past 4 months.
Examination: There was a depression at BL-18. She had a Liver Wind and possible Shen disturbance with the head tilt and ataxia. The tongue was slightly red and dry with no coating,and had a deeper red on the sides, associated with the Liver area. Pulses were strong and wiry, but slightly weaker on the right. Her urination, feces, voice, sleep, respiration ears, gums, appetite, and water intake were normal. There was a lateral downward strabismus to the left eye, and a 60 degree head tilt to the right. The walk was slightly ataxic. She circled to the left. She fell down if she attempted to jump.
Diagnosis:The ataxia, circling, depression at BL-18, Wood constitution, wiry pulses, red tongue with a deeper red on the sides (Liver area) indicate a Liver issue with Wind. The Shen disturbance with the head tilt, downward and lateral strabismus indicate Blood and/or Qi Stagnation in the head. Therefore the diagnosis is Blood Stagnation in the head with Liver Wind.
Treatment: Dry needle acupuncture was done at the following points:
- GV-14/20, GB-20/21/25, GB-25, BL-18/20/21/23/60, KID-3, and An-shen bilaterally
- 20 mg Depo Medrol was divided between BL-18/21 bilaterally
- 0.45 ml of Convenia was given at left GB-25
She went home on Stasis in Mansion of Mind 0.2 gm capsules BID for 6 weeks. It was chosen to break down Blood stasis in the brain and to transform Phlegm. For the first 3 days she had greatly improved with much less head tilt. She was as the owner put it, “able to stick her landings” after she jumped. She was now jumping off of the table without fear.
Examination August 2, 2014:
Her gums were pink. There was less of a head tilt and a more mild strabismus. She had deep pulses which were weaker on the right. Her tongue was pink with a hint of purple. There were slight depressions at BL-18/21/23.
Treatment: Dry acupuncture needles were given at the following points:
- GB-21, GV-3/14/17/20,
- KID-3, and Shen bilaterally
- 0.45 ml Convenia was given at left GB-25.3 cc
- B12 was given at GB-21 bilaterally
- GV-14 20 mg Depo Medrol was divided between BL-21 bilaterally
The owner was instructed to continue to give Stasis in Mansion of Mind 0.2gm bid and return in 2 weeks.
Follow up telephone conversation September 3, 2014:The cat is normal without a head tilt or ataxia. The owner decided the cat is doing so well that she no longer needed her third acupuncture treatment. She is still giving the herbal Stasis in the Mansion of Mind, which is almost finished.