Chief Complaint: Chest congestion with cough that started in the fall 3 years ago
Western Diagnosis: chronic bronchitis
Medical History: Medical History:a. History of Present Illness: The patient has been suffering from chest congestion with cough for over three years. The condition usually worsens in the months of October and November. It becomes aggravated with heat. 14 days ago it worsened and became a cold. The days before she got the cold, she went and took saunas and steam baths regularly for therapeutic reasons. She was hoping it would help her chest congestion. Two weekends ago it manifested as a cold. She has a dry, hacking cough. The cough contains phlegm which is difficult to expectorate and the color of it is yellow. In addition she has yellow sticky nasal discharge. She feels depressed that she is not feeling well.
b. Current Health Status: The patient complains of having chronic bronchitis which has been diagnosed by a medical doctor. When she had a cold she used “ibuprofen” to reduce the fever. Afterwards she used “cold calm” which is a homeopathic cold tablet. In addition she took multivitamins as supplements. She visited PCOM-clinic at 05/16/02. The acupuncture treatment and the herbs prescribed improved her energy level but didn’t completely resolve the chest congestion. She still feels fatigued after recovering from the cold. . She feels slightly depressed from not feeling well. She complains about not having restful sleep. She reports no dreams. She does not sweat any more but in her past she had sweating episodes in the morning. Her appetite diminished during the cold attack but today it is back to normal. She eats three meals a day consisting of meat, vegetable and starch and has no particular cravings. She reports no bloating or abdominal pain after eating. She has bowel movements once a day and they are usually well-formed. The patient describes her self as a little bit more thirsty than normal. She drinks 4- 5 cups of liquid. She prefers warm drinks and she drinks mostly teas. Her urine is bright yellow and she urinates 6-7 times a day. She also usually wakes up once during the night to go to the toilet. There are no complains of headache or body pain .She reports premenstrual problems manifesting as heavy cramps , anxiety and breast hardening. Her menstruation started 9 days ago. It flowed for 4 days. The color of the menstruation was bright red with dark red colored clots. The first two days she was bleeding heavy. On the third day it was a medium flow until it subsided the fourth day. During the treatment the patient reported great sensitivity on the balls of her feet and to a lesser extent over the whole bottom of the feet. She was embarrassed of a long lasting fungal infection on the feet which began in-between the toes and now is mostly on the nails.
c. Past
Medical History: Her last medical physical exam was 2 years ago. She has been diagnosed with drug allergies, asthma bronchitis and urinary tract infection. In 1980 she was hospitalized for pelvic inflammation disease and she was treated for an ovarian cyst.
d. Family Health
History: Her mother has high blood pressure and is 82 years old. Her father is 67 and is suffering from a heart disorder.
Questioning exam:Chest congestion
coughing up yellow phlegm that is difficult to expectorate
Nasal discharge that is yellow and sticky
fatigued
Pulse exam:Slippery pulse
Tongue exam:Thick white tongue fur
Reddish tongue body
More red on the tip
Central crack
Slightly more thirsty than normal
OM Diagnosis:a. The location of the disease has progressed internally.
b. The disease involves both deficient and excess components.
c. The disease involves heat.
d. Diagnosis – exterior cold with damp stagnation turning into heat and phlegm.
The patient has been suffering from chest congestion with cough for 3 years. The patient is not a smoker. The condition usually worsens in the autumn. It probably started out as a cold which never was resolved. The disease then progressed inwardly damaging the lung qi and leading to chronic chest congestion with a cough.
Fourteen days ago she got a cold. The saunas and steam baths she took prior to this may have aggravated her underlying chronic condition and made her less resistant to evil pathogens. The lung is the most vulnerable organ because it is in direct contact with the environment. By going to the sauna she exposed her skin and pores to the environment, possibly further injuring her protective qi and thus allowing the pathogen to enter. At the time of the attack the weather was very cold. There may have been a wind-cold pathogen invading the body.
When the patient consulted us there where more or less no signs of wind-cold. There were more signs of heat and phlegm. I therefore suspect that the pathogen has entered the interior and attacked the lung organ.
The lung’s function is to disperse and descend qi and body fluids. The patient’s cough was caused by lung qi which was not descending properly due to an obstruction. Normally, the lung sends qi down to the kidney. If the kidney fails to grasp the qi, it rebels upward, impairing proper respiration.
Impairment of qi and fluid circulation in the chest leads-to chest congestion. Exterior wind-cold pathogens also impair circulation as cold tends to constrict. It is said that the spleen makes phlegm and the lung stores the phlegm, the patient was coughing yellow phlegm which was difficult to expectorate. This leads me to think that the patient’s ability to transform the fluid was interrupted. The lungs normally receive pure vapor from the spleen, disperse the clear fluids throughout the body and send the impurities down to the kidney. Instead of descending, it seems that the impure fluid has accumulated and led to the retention of phlegm in the lungs. Over time, this obstruction has given rise to heat. Slight thirst and phlegm which is difficult to expectorate may have arisen due to this heat consuming the body fluids. It is said that the lung opens into the nose. An impairment of the lung’s functions of dispersing, protecting and nourishing would explain the patient’s nasal congestion. The yellow, sticky nasal discharge tells us that heat and dampness is involved.
The lung and the spleen are the main organs involved in making qi. The long-standing congestion and the attack by an exterior pathogen have weakened her lung and spleen qi. Over time, this has fatigued the patient to the point that she feels depressed.
Considering the patient’s tongue, pulse and nasal discharge leads me to believe that there is some damp or phlegm-heat lodging in the interior. The thick white coating at the back of the tongue is an indication of excess turbidity of the stomach and spleen. The patient may have started out with a thinner coat in the front, but the thickening in the back of the tongue indicates that the pathogen has moved to the interior. We would suspect to see a yellow coat if there where heat involvement but I believe because we are looking at a long standing cough it is not yellow any more. The reddish color of the body confirms the presence of heat. The redness of the tip of tongue makes me think of heat in the upper burner. The central crack or groove tells me that there may be some spleen deficiency involved and heat injuring the fluids. The dampness is reflected in a viscous-feeling, slow and slippery pulse. The deep pulse indicates an interior condition.
Overall this patient reflects a dysfunction of the qi and body fluids. The main organs involved are the lung and spleen. The chronic congestion has led to damage of the lung qi and weakened the protective qi, thus allowing a pathogen to enter the body and disrupt the interior. The long standing fluid impairment has caused heat and phlegm to linger in the lung.
Treatment Principle: Drain Damp, Clear heat and Transform Phlegm.
Point Prescription: Acupuncture Points:
LU1 -front mu : clears and diffuses the upper burner and courses lung qi.
LU7 – luo connecting. : diffuses lung
- command head : specifically back of head, nape of neck
LI11 – he-sea, earth : courses pathogenic heat, eliminates water damp.
ST40 – luo connecting : transforms phlegm damp.
LI20 : unblocks nose and clears qi fire.
YINTANG – extra points : quickens collaterals, quiets the spirit.
UB67 -jing well, metal : rectifies qi and clears the brain.
. Acupuncture Analysis:
1. LU1 – is where the lung qi collects. It is the first point on the exterior channel. Therefore it is an effective point for cough and transforming the phlegm.
2. LU7 – it has an interior and exterior relationship with the large intestine channel which goes to the face. It regulates the body fluids and qi in the head and face relieving nose obstruction and phlegm accumulation with a cough.
3. LU1 and LU7 create movement in the chest and relieve qi constraint thereby inducing proper respiration.
4. LI 11- is the earth point and therefore the mother point of a metal channel. The fact that it is a he-sea point indicates that it can be used to treat more interior conditions. As this point also clears heat, it is a good tonifying point for coughing up yellow phlegm that is difficult to expectorate.
5. ST40- the stomach channel travels over the chest goes to the face and normalizes the sense organs. The spleen makes phlegm, the lungs stores phlegm. Thus, this luo point which stands in an interior and exterior relationship to the spleen, is a very good point for chest pain caused by phlegm. It benefits the lung to disperse the body fluids.
6. LI20 – is a local point of the upper or yang part of the body. Thus, it is good for clearing heat signs, like yellow nasal congestion – also exterior and interior relationship to lung
7. LI11, ST40 and LI20 all belong to the yang-ming channel. These channels are both abundant with qi and blood. The stomach channel is also the only yang channel traveling along the front of the body. This combination of points has a quality of supporting the transformative action of the spleen. At the same time they can clear heat and benefit the fluids.
8. YINTANG – is a nice point to calm down the patient and clear the nasal passage
Herbal Formula: Herbs (Patent Medicinal)
Clear the qi and transform the phlegm pill; QING QI HUA TAN WAN
DAN NAN XING – transforms phlegm heat
BAN XIA – dries dampness, transforms phlegm and causes qi to descend
GUA LOU REN – transforms phlegm heat and expands the chest
HUANG QIN – clears heat and dries dampness
CHEN PI – improves the transportative function of spleen, dries damp and transforms phlegm
XING REN – stops cough
ZHI SHI – transforms phlegm and redirects qi downward
FU LING – strengthens the spleen and transforms phlegm
d. Herb Analysis:
These herbs primarily address the symptoms of cough with phlegm which is difficult to expectorate and chest congestion.
Most of the herbs in this formula affect the qi and body fluids. They improve the dispersion action of the lung by clearing heat and redirect qi downward. At the same time they support the spleen in transforming and transporting the fluids. “The fire and phlegm interfere with the descending function of the lung qi, which leads to coughing with sputum that is difficult to expectorate” (Bensky 1990).
Dan Nan Xing strongly drains phlegm heat from the lung; Huang Qin and Gua Lou Ren reinforce Dan Nan Xing and work together to clear phlegm heat from the lung. Zhi Shi and Chen Pi both regulate the middle burner and assist in transforming phlegm. Fu Ling supports the transformation of damp and phlegm. Xing Ren stops cough and Ban Xia strongly expels the phlegm.
Working together, the herbs will disperse any chest obstruction which would lead to the greater accumulation of phlegm heat.
“When there is a surfeit of qi, fire results, when there is surfeit of fluid, phlegm results. Therefore in treating phlegm it is necessary first to direct fire downward, and in treating fire it is necessary to smoothen the flow of qi.” (Wang Ang in Analytic Collection of Medical Formulas, Bensky 1990, p.437)
Lifestyle Prescription: None
Results: Slowly improvement over three weeks periode. At a checkup, after 3 month has passed, she still felt very good.
Synopsis: Overall this patient reflects a dysfunction of the qi and body fluids. The main organs involved are the lung and spleen. The chronic congestion has led to damage of the lung qi and weakened the protective qi, thus allowing a pathogen to enter the body and disrupt the interior. The long standing fluid impairment has caused heat and phlegm to linger in the lung.
