Record of First Visit
Name of Student Clinician: Suk Yee Chan Ho Name of Supervisor: Yueping Li
Date of first visit: 10 June 2008 Gender: Female Age: 45
Chief complaint/s(chronic or acute): Severe coughing for one week
Description (4 diagnostic methods):
A) Asking:
Caught cold for one week, running nose with clear nasal discharge, but now turn to yellow sticky discharge. She went to see western doctor and took western medicine 3-4 days ago. After that, fever was gone.
Present symptoms : Sore throat, severe coughing with burning sensation, dry throat, dry mouth, thirsty, warm drinks preferred, bitter taste, aversion to cold, chill, no fever, headache, mostly forehead, sometimes the whole head, whole body aching, feel cold at the back, shoulder and nape, tight chest and sore chest after coughing, hard to cough out phlegm, not feel like to eat and feel tummy full, no belching, no abnormal sweating, no night sweating, normal defecation and urination, usually good sleep but in these 3 days poor sleep, tinnitus always.
Past history:
Heavy uterus bleeding in 2003
Life Style: Fulltime student and a housewife
Family history: NAD 4-5
Menstruation, marital & obstetrical history: 15--------- 4 days ago (
45-55 married with 2 children
Inspection:
General: Tired complexion, normal movement, normal mental state, big figure,
Others: NAD
Tongue: Dim, corpulent, with teeth marks, dry thin white coating
C) Auscultation/Olfaction:
Sound: Nasal sound, difficult breathing because of the nasal obstruction
Odours: No bad odours
D) Palpation:
Body Areas: Cold at upper back and shoulder when palpated
Pulse: Rapid and thin in general
Case Summary
Definition:
Cough, a main symptom of the lung problems, may result either from attack by exogenous factors disturbing the dispersion of Qi of the lung, or from disorders of the lung itself or other diseased Zang-fu organs of affecting the lung. In modern medicine, cough is commonly seen in upper respiratory tract infection, acute and chronic bronchitis and tuberculosis.
WMS:
A cough, also known as tussis is a sudden, often repetitive, spasmodic contraction of the thoracic cavity, resulting in violent release of air from the lungs, and usually accompanied by a distinctive sound.
Coughing is an action the body takes to get rid of substances that are irritating the breathing passages. A cough is usually initiated to clear a buildup of phlegm in the trachea. Coughing can also be triggered by a bolus of food entering the trachea rather than the esophagus due to a failure of the epiglottis. Frequent or chronic coughing usually indicates the presence of a disease. Provided the patient is a non-smoker and has a normal chest X-ray, the cause of chronic cough in 93% of all patients is due to asthma, heartburn or post-nasal drip. Other causes of chronic cough include chronic bronchitis and medications such as ACE inhibitors. Coughing can happen voluntarily as well as involuntarily.
TCM Aetiology and Pathology
1. Invasion by the Exogenous pathogenic Factors
The lung dominates Qi and is regarded as an umbrella protecting the five Zang-organs. Upward it connects the throat and has its opening in the nose, governing respiration. Externally it associates with the skin and hair. Once the lung is attacked by the exogenous pathogenic factors, the defensive system of lung is invaded by pathogenic factors; the Qi of the lung is blocked and fails to descend, thus resulting in cough. Since the weather changes in different seasons, the exogenous pathogenic factors attacking the human body are various, cough is therefore divided into two types: wing-cold and wind-heat.
2. Internal Injury
Cough resulted from functional impairment in the Zang-Fu organs, falls into the category of cough due to internal injury such as cough by dryness of the lung with deficiency of yin leading to failure of Qi of the lung to descend; cough caused by the deficiency of the spleen which gives rise to internal dampness whose excessive accumulation produces phlegm. Phlegm damp in return may go up into the lung, causing the dysfunction in descending, cough resulting from stagnation of liver-qi may be turned into fire, flares up and injures the lung fluid, and cough is due to deficiency of liver and kidney-yin, and the dysfunction of the lung in descending and dispersing.
Syndrome differentiation:
Invasion by exogenous pathogenic factors:
1. Wind-cold
Main manifestation:
Cough, itching of the throat, thin and white sputum, aversion to cold, fever, headache, stuffy and running nose, thin white tongue coating and superficial pulse.
2. Wind-heat
Main manifestation:
Cough with yellow and thick sputum, choking cough, thirst, sore throat, fever, or headache, aversion to wind, sweating, thin, yellow tongue coating, floating and rapid pulse.
Internal injury
1. Blockage of the lung by phlegm
Main manifestation:
Cough with profuse, white and sticky sputum, stuffiness and chest congestion, loss of appetite, white, sticky tongue coating and rolling pulse.
2. Deficiency of yin with dryness of the lung
Main manifestation:
Dry cough without sputum or with scanty sputum, dryness of the nose and throat, sore throat, spotting blood or even coughing blood, afternoon fever, hot flush, red tongue, thin coating, rapid, and thready pulse.
TCM Diagnosis:
Cough
Syndrome Differentiation:
Shaoyang Syndrome
Explanation:
Shaoyang syndrome occurs when the exterior evil is not removed and the genuine-qi is insufficient. The genuine-qi and evil qi fight each other between the exterior and the interior. The pathological changes take place between the exterior and the interior.
The patient has caught cold a week ago, and she had taken the western medicine which suppressed the symptom of fever, but had not really removed the exogenous evil. The condition is just the same as the Shaoyang Syndrome.
The manifestations are alternate fever and chill, aching body, aversion to cold, chest distress, reluctant to eat, dryness in throat, mouth and tongue coating. Since the patient’s cold has happened for a week, the evil is not staying in the exterior, but in between half ways. It develops into an internal injury to the zang-fu. So her cough is caused by the dryness of the lung with the yin deficiency, leading to the spleen deficiency which gives rise to internal dampness whose excessive accumulation produces phlegm. Phlegm damp goes up into the lung, generating heat, causing sore throat and difficult to expectorate sputum.
The patient does not like to eat and have full tummy, tight chest, bitter taste because the Shaoyang meridian travels through the chest; the Gallbladder qi, which is suppressed by the evil, invades the stomach, causing the above symptoms.
The rapid and thin pulse indicates the internal heat produced by the yin deficiency. The dim and corpulent tongue body suggests the qi deficiency.
Treatment Principles:
Harmonize Shaoyang
Points, Therapies and Explanations:
Using filiform needles with even method to harmonize the Shaoyang
Zusanli ± ---the He-sea point of the Stomach meridian , supports the genuine qi and fosters the original qi,
Chize ± --- the He-point of lung meridian, clears heat from the lung and descends rebellious qi,
Waiguan ± ---Luo-connecting point of SJ, expels wind and releases the exterior
Yanglingquan ± --- He-sea point of Gallbladder, harmonizes Shaoyang
Life Style Advice
Do regular exercises to strengthen body
Sleep early and wake up early
Eat more vegetables and fruits
Drink more water
Have a fresh air environment
Case Conclusion
The patient’s complaint is severe cough for one week. The diagnosis is Cough and the syndrome differentiation is Shaoyang Syndrome. It is the half-exterior and half-interior syndrome, in which exogenous evil is not yet removed but fighting with the genuine qi in the half way. The patient’s symptoms are fit to this category. The most significant symptom is the alternate chill and fever. Although the patient claimed that she had no fever, it was only suppressed by the antibiotics she has taken for 3 days. The patient is aversion to cold and feels cold, but at the same time, she has sore throat and burning sensation when she is coughing. The treatment principle is to harmonize Shaoyang. So the manipulating method is even. The chosen points are: Zusanli ± Chize± Waiguan ± Yanglingquan ±. Unfortunately, the patient did not come again because she went to see the western doctor. I have no chance to see the result.
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