This is really more "Why did my patient die?". At this point it won't affect the outcome of this case, but I just wanted clarity to carry with me to the next one.
Lady's tongue was consistently red, usually dry with a wet tip, sometimes with dry phlegm lines. Pulses were alsways deep and weak (you said from Damp Heat damaging Qi). Originally LDXGT and Si Miao San worked, but within the last month she stopped eating any food with powders in it and picking out pills. She would pant for a couple hours after eating, and intermittently throughout the day in a cool cage at work. The only time I saw any purple on her tongue would be sometimes after a meal. Slept fairly well through the night, until the last week when she had one night that she passively vomited foam and foamy yellow mucous (after feeding ID for diarrhea from Zhi Bai Di Huang Wan), and the last might where she was up all night panting and uncomfortable. At the end, all her GIT would tolerate was raw meat and vegetables. If the food was anything other than a soupy consistency, she would also weakly vomit thick white foam. I was never able to find active GB points (a weakness of mine!)
I know I had a mix of excess (Damp Heat, Phlegm, stagnation), and deficiency (Spleen Qi, source Qi, Yin-KIDney and Liver), Phlegm obstructing the descent of Stomach Qi. I know that the chronic Damp Heat damaged Yin, Qi and Blood, leading to toxic Damp Heat and Qi-Blood entanglement in the Middle Jiao.
Once I got past LDXGT and Si Miao San, I was never able to get a handle on any treatment strategy that worked without V/D. I tried a low dose of YGJ, ZBDHW, or Da Bu Yin Wan-all resulted in diarrhea. SHen Ling Bai Zhu, San Ren Tang and Si Miao San helped but by themselves weren't enough. Bao He Wan and Ping Wei San Plus from East Tao helped with the vomiting and Phlegm, but I felt were more symptomatic treatment than TCVM and were drying to damage already depleted Yin. Corydalis and Tramadol helped with pain for a while, but then I became unsure if pain was really the main issue.
At the end I eventually saw the scary, brick red tongue with purple undertones and performed her euthanasia.
My queston is-could you explain to me how you see the progression of this case and any suggestions you have for different interventions along the way. I have lost my objectivity through tears.
Thank you, Jodi