Patient: Male, 40 years old.
Chief Complaint: Severe cough for several days without obvious cause, accompanied by difficulty breathing similar to asthma.
Medical History:
The patient had previously taken Qingfei Xiaoyan Wan and Lihuo Pian for a week, which initially alleviated the cough. However, two days later, the cough recurred and worsened.
Current Symptoms:
Severe cough, especially at night, making it difficult to sleep. The cough is accompanied by thick white phlegm that is hard to expectorate. Prolonged coughing leads to wheezing and chest pain. The patient experiences dry mouth, dry and rough tongue, and a strong desire to drink water. Cold lower limbs, occasional night sweats, and increased breathing difficulty when taking a bath.
Tongue Diagnosis:
The tongue image provided was somewhat blurry, showing a thick white coating. It could be a cold white coating or a dry white coating. Given the patient’s symptoms and underlying liver-kidney yin deficiency, it was assessed as a dry coating.
Pathophysiological Analysis:
Lung and kidney yin deficiency leads to a lack of lung moisture, resulting in severe coughing with thick, difficult-to-expectorate phlegm. Prolonged coughing depletes qi, causing impaired lung function and breathlessness. Lung collaterals are damaged, leading to qi stagnation and blood stasis, resulting in chest pain. Yin deficiency with internal heat depletes fluids, manifesting as dry mouth and thirst. Kidney yang deficiency weakens warming functions, causing cold lower limbs. Yin deficiency leads to an unstable defense mechanism, resulting in night sweats. Breathing difficulties while bathing may be due to increased lung heat and weakened lung qi.
Treatment Plan:
Combined classical herbal formulas:
1. Maimendong Decoction (Mai Men Dong Tang)– Nourishes yin, moistens the lungs, and stops coughing.
2. Ding Chuan Shenqi Dan – Clears the lungs, descends qi, and relieves cough and wheezing.
3. Qianjin Weijing Decoction (Qianjin Wei Jing Tang) – Clears the lungs, resolves phlegm, and eliminates heat and stasis.
Treatment Outcome:
After taking the first dose, the cough significantly reduced, though mild wheezing remained. After three more doses, both the cough and wheezing ceased, allowing the patient to sleep peacefully at night.
Case NO.109 @ TCMDrMa.com Online Consultation
Note: TCM doesn’t ‘treat’ any certain WM disease name. TCM has its own system and method to rebalance the human body, release the symptoms and help the body truly recover on its own. TCM treatment methods and effects are different according to individual differences, and the sharing of the case study does NOT constitute treatment recommendations.
Published @January 30, 2025 | Author Max Ma | TCMDrMa All Rights Reserved
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