Sjogren syndrome-Tympanitis Syndrome due to Spleen, Liver, Kidney deficiency

[Michael]

SETCION 1: GENERAL INFORMATION
Sex: Female
DOB: 1923
Occupation: Retired
Date of First Visit: 06th March 2003

SECTION 2: DATA COLLECTED FRM FOUR DIAGNOSTIC TECHNIUES
2.1 INQUIRIES:
2.1.1 Chief Complaint: Interrupted abdominal distension with asthma for 4 month and aggravated in the last 3 days.

2.1.2 Present case history: 3 days ago, patient had abdominal pain with worsen asthma, which she had for many years. Five years ago, the patient being diagnosed with Liver cirrhosis. She had been taking Chinese herbs and pattern herbs in the last 2 years. She had dry mouth, dry nose, nasal bleeding, subcutaneous bleeding, chest oppression feeling, insomnia, oliguria, diarrhoea, and poor appetite. There were no aversion to cold, no fever, no vomiting, and no nausea.
2.1.3 Previous history: 3 years ago, the patient was diagnosed with Sjogren syndrome. She used to use Penicillin 10mg/day, and she ceased medication stopped 6 months ago.
2.1.4 Personal history: No drinking, no smoking. 13. 5/28. Menopause at 49 y.o.
2.1.5 Family history: N/A.

2.2 INSPECTION/OBSERVATION:
2.2.1 Spirit: Consciousness: spirit – low
2.2.2 Complexion: Yellow and wither complexion.
2.2.3 Appearance: Facial crease normal.
Normal development
No deformation
Tongue in the middle not deviated.
Pitty oedema on both legs.
2.2.4: Body stature: distended abdomen
2.2.5: Tongue: white & slightly greasy, dry and peeled, yellow coating.
2.2.6: Other parts of the body:
Cyanosis of the lips
Subcutaneous bleeding of the skin
2.2.7 Excretion and Secretion: Diarrhoea, oliguria

2.3 AUSCULTATION & OLFACTION
2.3.1 Auscultation:
Respiration sound – normal, no rale sound, heart rate 80 beat/min – regular.
No pathogenic murmur sound
Tendon reflex normal (++)

2.4 Palpitation:
2.4.1 Pulse: Slippery and rapid pulse.
2.4.2 Palpating different parts of the body: Pitty Oedema at lower legs

[Michael]

SECTION 3: WESTERN MEDICAL RECORDS
3.1 Physical examination: (Positive signs)
T(38.5oC), P(100 beat/min), R(20 breaths/min)), B(120/75 mmgH)
Shift down is +ve
Percussion pain at Liver region
3.2 Laboratory tests results
Urine test: white blood cell increased 4.3 (4-10)
HGb: 80 (100-150) Anemia (likely o have hyperactivity of spleen)
Kidney function: Na+ increase (135 - 143)

SECTION 4: DIAGNOSIS SUMMARY:
4.1 Chinese Medicine Diagnosis
Gu Zhang- Tympanitis Syndrome due to Spleen, Liver, Kidney deficiency.
4.2 Western Medicine Diagnosis
Sjogren syndrome (A systemic inflammatory disorder characterized by dry mouth, decreased tearing, and other dry mucous membranes and often associated with autoimmune rheumatic disorders)

[Michael]

SECTION 5: DIFFERENTIATION AND ANALYSIS
5.1 List all the evidence of the differential diagnosis:
Weak Liver, unable to disperse Qi
Weak Kidney unable to control the water.
5.2 Analysis of the Aetiology and pathogenesis
Due to the age of the patient resulting weakness of the 5 Zhang organs. Spleen deficiency weaken the Transport and Transform functions and resulting dampness retention in the middle jiao.
5.3 Principles of treatment:
Nourish Liver and Kidney, eliminate dampness and water retension.
5.4 Prescriptions and Administration
TaiZiSheng10, ZhuLing12, FuLing12, CangZhu10, BaiZhu10, ChiShao10, BaiSHao10, XinRen10, SangBaiPi10, DangGui10, ZeLang12, ZeXie10, CheQianZi10, YiMuCao10, DaFuPi10, YiYiRen10.