CASE STUDY

Mrs F, 59 year old female, retired

1. Main complaint: Chronic cough over 5 years and got worse for 2 months
2. Present history: Time of onset of major symptoms
1. Model of onset
2. Character
3. Severity
4. Aggravating and relieving factors
5. Associated symptoms
Mrs F came into the clinic complaining of a cough of over 5 years duration.
She was diagnosed at polymyositis (PS) in September 2009, a rare
inflammatory disease that leads to muscle weakness and pain, difficulty
swallowing, voice problem, etc. She received prednisone 30 mg and
maintaining dosage at 5 mg. Since then, she frequently cough up respiratory
infection and coughs up thick sputum that was yellowish-white in colour and
controlled by antibiotics. Her chronic cough is often with profuse mucus and
has a sticky texture and it is very easy to cough up. The coughing often
comes on after eating. The severity of the cough seems to have gotten worse
in the last months with family stress, sticky sputum in white colour. Currently
she has no fever, no sore throat, no sweating.
Current treatment: prednisone 5 mg/day
Crestor 5mg for high cholesterols
Avapro (irbesartan) 150 mg for hypertension

Menstrual history: post menopause, no symptoms

General conditions: She also mentioned digestive complaints with suffering
from bloating, nausea and vomiting and also has mucous in the stools, normal
bowel moment and urination, muscle pain and fatigue, stress, difficult in losing
weight, like warm drinks, feel body heaviness
3. Relevant past history/social history/personal): She was a smoker during
her 20s and 30s but she does not currently smoke,
eating healthy diet, do exercise every day

4. The Family History

There is no history of similar illness in her family
5. Physical examination/Observation
Tongue: purplish-pale body, teeth marks, thick white coat
Pulse: thin and slippery
Height: 167cm
Weight: 95kg, BMI: 34
Ankles pitting oedema IIo
BP: 120/80 mmHg

Auscultation: no abnormal sound in the lungs

6. Lab tests: request for previous test report related to inflammatory disease
suggest to take blood biochemistry test, ESR, CRP and ANA
full blood count test

7. The assessment and analysis for disease mechanism

Analysis of signs and symptoms:

Chronic cough with whitish sticky mucus indicate lung qi dysfunction and
sleep qi failed to transform body fluid
Longer term chronic disease--> Qi weakness --> blood stasis --> muscle weak
and aching
Stress-->liver qi stagnant--> affect qi and blood flow --> blood stasis

Cause of disease: chronic disease and prednisone damage Zheng Qi

(compromised immunity)

Site of disease: affected organs/channels, or tissues:

Major affect organs are Lung and Spleen, Liver qi stagnation results
weakness of lung and spleen function to disperse fluid

Pathological change: The root of disease is Spleen QI deficiency -->lung qi

deficiency

Differential diagnosis: exclude other causes and diseases

Respiratory infection? Not support evidence
No fever, no chest pain and sore throat

Diagnosis

TCM disease name: Cough syndrome

Western medicine diagnosis: Chronic cough related to polymyositis

diagnosis with examination results in her medical record by Specialists

TCM pattern: Lung qi and spleen qi deficiency --> fluid accumulation

Weakness of Qi and liver Qi stagnation --> blood stasis
Treatment approach and plan
Strength Spleen and lung Qi to dissolve dampness
Regular lung qi to clear phlegm and control cough
Active blood to relieve muscle aching
Regulate immunity to control inflammatory disease

Acupuncture: points and method ( patient preferred CHM to

acupuncture)
Strengthen Sp and dissolve dampness; Active blood to relieve muscle aching
Sp9, Sp6, Sp10, St36-Li10, St40,
Strength and regulate Lung Qi to disperse fluids and control cough:
Lu1, Cv20, L9,
Regulate immunity to control inflammatory disease:
Cv6, Cv12, Bl13, Bl17, Bl18, Bl20, Bl23, Gv 20, Gv 4

Chinese Herbal prescription:

Huang Qi 20g,

Fu Ling 15 Sang Ye15 Cheng Pi 10g

Yin Xing Ye 15g

Dang Gui 10g

Dan Sheng 30g

Gan Cao10g Zhi Ke 10g Lai Fu Zi 12g Chuan Xin Lian 15g

Bai Shao 30g

Treatment duration: herbal medicine for 2 weeks then follow-up treatment

Others treatment: no change for current medication

Advice for life style: control stress

Expected months treatment is necessary for significant improvement

Herbal-drug interactions? Herbal medicine has no adverse interaction with

current medications taking. The modification on dosage of Prednisone
5mg/day, e.g. cutting down dose, it should be based improvement of clinical
symptoms and by consulting her MD.

After 3 months of treatment, her cough and mucus was controlled,

muscle aching and abdominal blotting were improved, reduced BWT,
good mode and feels energetic, and taking 2.5mg Prednisone/day.
Patient on and off with CHM treatment over 1.5 years, her polymyositis
is stable and body inflammation is controlled well, no much cough and
no lung infection.

Understanding underlying disease of her respiratory symptoms:

Polymyositis is a rare inflammatory disease that leads to muscle weakness, swelling
tenderness, and tissue damage
Common symptoms include:

Difficulty swallowing
Muscle pain
Muscle weakness in the proximal muscles (shoulders, hips, etc.) this can
make it hard to raise the arms over the head, get up from a sitting position, or
climb stairs
Problems with the voice (caused by weak throat muscles)
Shortness of breath

Exams and Tests

Tests may include:

Autoimmune antibodies and inflammation tests

CPK
Electromyography
MRI of affected muscles
Muscle biopsy
Myoglobin in the urine
Serum aldolase

Treatment
corticosteroid medicines:
immunosuppressant drugs can control the disease.
Prognosis and complications
Response to treatment varies based on the complications. The 5-year mortality rate
can be as high as 1 in 5 patients due to

Malnutrition
Pneumonia
Respiratory failure
Severe, long-term muscle weakness

The major causes of death are cancer and lung disease.