Psoriasis-Bai Bi, Due to Wind Dryness caused by Yin Blood deficiency

[Michael]

SECTION 1: GENERAL INFORMATION
Sex: Female
DOB: 44 years old
Date of First Visit: 3rd July 2003

SECTION 2: DATA COLLECTED FROM FOUR DIAGNOSTIC TECHNIQUES
2.1 INQUIRIES:
2.1.1 Chief Complaint: Recurrent itchy pink papules and plaques with distinctive borders around elbows and legs for 17 years.

2.1.2 Present case history: The patient had recurrent itchy pink papules and plaques with distinctive borders around elbows and legs for 17 years. The lesions recurrent and aggravated to severely aggravated through the whole body since early this year. It started about 17 years ago with lesions only around elbow and lower limbs.
The lesion caused itchiness, and scratching resulted dry scaling.
The patient was disgnosed with typical psoriasis and treated at other hospital with Tripterygium Wilfordii derivative medication in May 2003, which caused decreasing of white blood cells. The treatment was ceased and later visiting at the clinic, she was admitted to the in-patient department. Her appetite, sleep, bowel and urination were all good.
2.1.3 Previous history: G1P1, full term infant, nature delivery. 13,5/29 LMP 29th June 2003.
2.1.4 Personal history: Vaccination up to date. History of Hepatitis B for 8 years. No allergic.
2.1.5 Family history: The patient had no family disease, no allergic.

2.2 INSPECTION/OBSERVATION:
2.2.1 Spirit: Consciousness: spirit – normal, alert.
2.2.2 Complexion: Skin and mucus – no jaundice, no bleeding. Sclera – Normal.
2.2.3 Appearance: Lesions of itchy pink papules and plaques with distinctive borders around limbs, abdomen, and back. No changes of nail, no joint pathology, Normal development / Tongue in the middle not deviated. / No oedema on both legs.
2.2.4: Body stature: All neural responses were normal
2.2.5: Tongue: Pink red tongue body, with yellow thin coating.
2.2.6: Other parts of the body: Tonsil – normal / Pupil – symmetric, reaction normal. / Eye balls moves freely without tumbling. / Throat –reflex normal. / Neck – soft / Trachea – in the middle / Thyroid – normal / Thorax – symmetric
2.2.7 Excretion and Secretion: Bowel and urination were normal

2.3 AUSCULTATION & OLFACTION N/A

2.4 Palpitation:
2.4.1 Pulse: String Taut

Tripterygium wilfordii

[Michael]

SECTION 3: WESTERN MEDICAL RECORDS
3.1 Physical examination: (Positive signs)
T(36.2oC), P(78 beats/min), R(18 breaths/min), BP (120/80 mmHg)

SECTION 4: DIAGNOSIS SUMMARY:
4.1 Chinese Medicine Diagnosis
Bai Bi. Due to Wind Dryness caused by Yin Blood deficiency.

4.2 Western Medicine Diagnosis
Psoriasis

[Michael]

SECTION 5: DIFFERENTIATION AND ANALYSIS
5.1 List all the evidence of the differential diagnosis:
Yin Blood deficiency – long term disease, dry skin scaling.
Wind dryness – aggravating of condition all over the body.
Blood heat – yellow tongue coating, dryness of the skin.

5.2 Analysis of the Aetiology and pathogenesis
Due to the initial wind-dryness attack, it damaged the lung and manifested as skin condition. Long term illness resulting blood deficiency, and with aging, blood yin been consumed which progressed the disease condition. Lately external wind-heat aggravated the condition with blood heat and yin deficient heat.

5.3 Principles of treatment:
Clear wind-heat, moisten dryness, tonify yin-blood.

5.4 Prescriptions and Administration
04.07.2003
External wash, XueDanSheng IV injection, JiaWeiHuangQinGao IV injection
TuFuLing30g, ShengHuaiHua15g, ShengDi15g, ChiZhao10g, BaiXiangPi10g, ZiCao15g,
DanPi10g, SHeSheCao15g, WuQiaoShe10g, HuMa10g, ShengGanCao5g   

07.07.2003 add ShuiNiuJao15g, RenDongTeng30g, LiangQiao10g
11.07.2003 add BaiMaoGen20g, QianCao15g
14.07.2003 Psoriasis still red
18.07.2003 add DangGui 10g
21.07.2003 red papules had been spreading, but old plaques been reduced and eased.
Adding astringent herb, WuMei15g.

5.5 Measures of prevention and health care.
Diet control, no spicy, greasy food, and less sea food.