Common acne-damp-heat from Lung and Stomach, with Liver Qi stagnation

[Michael]

SECTION 1: GENERAL INFORMATION
Sex: Male
DOB: 19 years old
Occupation: Student
M.S.: Single
Date of First Visit: 18th July 2003

SECTION 2: DATA COLLECTED FROM FOUR DIAGNOSTIC TECHNIQUES
2.1 INQUIRIES:
2.1.1 Chief Complaint: Facial red and purple papules and lesion for 6 years, aggravated for 3 months.

2.1.2 Present case history: The patient has facial red and purple papules and lesion 6 years ago and was diagnosed with acne. 3 months ago, the acne aggravated to the size of a little finger, and in creased in amount on face. There were no acnes on any other parts of the body. The patient was under stress 3 months ago due to studying for examinations.
2.1.3 Previous history: Been treated at local hospital 8 days for acne with aggravated conditions before admitted to this teaching hospital.
2.1.4 Personal history: Vaccination up to date.
2.1.5 Family history: No heredity disease. The patient had no family disease, no allergic.

2.2 INSPECTION/OBSERVATION:
2.2.1 Spirit: Consciousness: spirit – fine
2.2.2 Complexion: Skin and mucus – no jaundice, no bleeding. Sclera – Normal. Slight dark-red facial skin.
2.2.3 Appearance: 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: Red body, thin yellow greasy coating
2.2.6: Other parts of the body: 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
2.3.1 Auscultation:
Respiration sound – normal, no rale sound, heart rate 70 beats/min – regular. No pathogenic murmur sound.
2.3.2 Olfaction: N/A

2.4 Palpitation:
2.4.1 Pulse: taut
2.4.2 Palpating different parts of the body: lymph nodes not palpable.

[Michael]

SECTION 3: WESTERN MEDICAL RECORDS
3.1 Physical examination: (Positive signs)
T(36.7oC), P(70 beats/min), R(18 breaths/min), BP( 120/80 mmHg)
Large papules and lesions on the face, some nodules with pus, some with black and/or white comedones.

SECTION 4: DIAGNOSIS SUMMARY:
4.1 Chinese Medicine Diagnosis
Acne with damp-heat from Lung and Stomach, with Liver Qi stagnation.
4.2 Western Medicine Diagnosis
Common acne

[Michael]

SECTION 5: DIFFERENTIATION AND ANALYSIS

5.1 List all the evidence of the differential diagnosis:Dampness: greasy tongue coating. Pus nodules and lesions.
Heat: Red tongue body, red face skin, red lesions and papules.
Liver Qi stagnation: Stress caused liver Qi stagnation resulting in internal heat. Causing disharmony of Liver, Stomach and Lung.

5.2 Analysis of the Aetiology and pathogenesis
Due to life style stress, the patient had liver Qi stagnation resulting in hyper active Liver yang disturbing Stomach and Lunch. The internal heat from the Liver Qi stagnation and organs’ disharmony rose to the upper body, the face; and manifested as rashes, papules, lesions and nodules.

5.3 Principles of treatment:
Clear damp-heat. Regulate Qi

5.4 Prescriptions and Administration
YuXIngCao IV injection,  DanSheng IV injection. External wash
19/07/2003
PiPaYe10g, SangBaiPi10g, HuangQin10g, ChaoShangZhi10g, BanZhiLang30g, PuGongYing30g, BaiHuaSheSheCao30g,   KunBu(Kelp)10g, HaoZao(seaweed)10g,QinPi+ChenPi 6g each, JueMingZi15g,  ShengShangZha15g

22/07/2003
add ZaoJiaoCi6g,  XiaKuCao15g

29/07/2003
add BanDiMu15g, ShiJueMing30g, LianQiao15g, YinChen10g

5.5 Measures of prevention and health care.
No greasy food.