Female, 60 years
Reason for consultation
Cough
Clinical history
The patient suffers from a repetitive cough of 4 years' duration. For one week, the symptoms have reappeared. She was diagnosed with bronchitis 4 years ago. The main symptom is non-asthmatic cough and it begins in winter and when she catches cold. One week ago, she was exposed to cold with a strong cough that worsens during the night. The patient can only sleep for 3 or 4 hours at night.
She has abundant white sputum, permanent feeling of cold but without fever, feeling of chest oppression. poor appetite, diarrhea (3/4 times a day)
Pale tongue with greasy coating, fine and slippery pulse.
Diagnosis
Analysis:
- First: chronic cough. Lung is affected every winter, Qi does not defend -> Qi deficiency. Confirmed by fine pulse and pale tongue, sensitive to cold.
- Now: cold attack that generates accumulation of cold Phlegm. If there were heat it would be with less sputum because the fluid would be consumed. The whole Tai Yin is affected -> Spleen Qi affected: poor appetite and diarrhea. Cold has weakened Spleen-Yang.
Recent and urgent Biao pattern: accumulation of cold Phlegm in the Lung. There is also a Spleen-Qi deficiency.
Therapeutic principles
- Eliminate cold Phlegm, release the lung (will calm the cough)
- Tonify lung and spleen