Case Study TCM

Name of Student clinician: Se Hyeong Jung

Name of Supervisor: Jessica

Date of Birth: xx.xx.1982 Gender: M

Chief complain: Common Cold for 2 days

Descriptions (4 diagnostic method)

A) Asking: He has been suffering from cold for 2 days. He played soccer in a heavy rain 3 days ago. And than he diretly go to bed without shower. 2 days ago he got running nose and blockage of nose at the same time. And also he got a cough. Next day he got silghtly fever and chill after took a shower.

No headache, no sweat, appetite is not good because he dosen’t want to eat any food. Normal urination and defecation. Sleep well and no dream.

Past history: NAD

Life style: drink alchool 2 times for a week and smoking half pack of cigarette for a week.

Family history: NAD

Menstruation:

B) inspection:

General: Normal body condition 7/10

Tongue: Thin body and white tongue coating.

C) Auscultation/Olfaction:

Sound: Hoarse Voice.

Odour: NAD

D) Palpitation:

Body area: NAD

Pulse: Deep pulse.

Case summary

WMS: Acute viral nasopharyngitis, or acute coryza, usually known as the common cold, is a highly contagious, viral infectious disease of the upper respiratory system, primarily caused by picornaviruses (including rhinoviruses) or coronaviruses.

Common symptoms are sore throat, runny nose, nasal congestion, sneezing and cough; sometimes accompanied by 'pink eye', muscle aches, fatigue, malaise, headaches, muscle weakness, and/or loss of appetite. Fever and extreme exhaustion are more usual in influenza. The symptoms of a cold usually resolve after about one week, but can last up to two. Symptoms may be more severe in infants and young children. Although the disease is generally mild and self-limiting, patients with common colds often seek professional medical help, use over-the-counter drugs, and may miss school or work days. The annual cumulative societal cost of the common cold in developed countries is considerable in terms of money spent on remedies, and hours of work lost.

The primary method to prevent infection is hand-washing to minimize person-to-person transmission of the virus. There are no antiviral drugs approved to treat or cure the infection. Most available medications are palliative and treat symptoms only. Megadoses of vitamin C, preparations from echinacea, and zinc gluconate have been studied as treatments for the common cold although none has been approved by the Food and Drug Administration or European Medicines Agency.

Definition: Cough, a main symptom of the lung problems, may result either from attack by exogenous pathogenic factors disturbing the dispersion of qi of the lung, or from disorders of the lung itself or other diseased zang-fu organs affecting the lung

TCM aetiology and pathology

1) Invasion by the exogenous pathogenic factors

2) Internal injury

3) Dryness of the lung with deficiency of yin

TCM diagnosis: Common Cold

Syndrome differentiation: Wind-Cold

Explanation: Invasion of the body surface by pathogenic wind and cold impairs the dispersing function of the lung and affects the nose, causing nasal obstruction and discharge. Pathogenic cold is of yin nature, which is likely to damage yang. Impairment of superficial yang is manifested by exterior symptoms such as fever and chill. Thin white coating and deep pulse are the signs showing the invasion of the lung and superficial defensive system by pathogenic wind and cold

Treatment principle: Expel cold and wind, relieve exterior symptoms.

Points: Fengmen, Lieque, Fengchi, Hegu

Moxa on Fengmen.

Explanations:

Fengmen : Eliminate wind cold and to relieve chills and fever.

Lieque: promote the dispersing function of the lung and to check cough.

Fengchi: Eliminate wind and cold

Hegu: Eliminate the pathogenic factors and relieve the exterior symptom.

Follow-up consultation

Lifestyle Advice

Skmoking is broken our body immune system so smoker getting easily illness thennon-smoker. Therefore, patient should be quit to smoking.

Eat healthy food three times for a day. And the patient has a rest.

Case conclusion

The patient received 1 treatment in total. At first he improved a lot because is the acute case.So he didn’t come to clinic anymore. I will use that treatment method this kind of patient.