Case studies

TCM Disease Differentiation

Patient is 52, male. He is a senior marketing executive, working for a large multi-national corporation. He is of medium height, average build, appears healthy, though worried and anxious.

The patient presents with chest pain. A few days ago he experienced a sharp stabbing pain in the upper left chest above the nipple which came on while driving to work into London from an outer suburb; the pain was severe, radiating down the Pericardium channel of the left arm to the elbow. The pain lasted a about 15 minutes. The patient says that he has been experiencing a mild pricking pain in the location described above on and off for the last six months. The onset has been gradual and come on during a particularly busy time and work. It is often worse in the morning on the way to work and in the evening when he is tired; it can also become worse during stressful meetings. However, when he is able to relax, such as at weekends, it can disappear completely. Over the last few months he has experienced dizziness in the morning after getting up.

He stopped smoking five years ago. He exercises at weekends - mainly walking, occasionally swimming. He has always enjoyed drinking a few pints of beer (sometimes more than a few) with friends. He becomes easily irritated, his working environment is very frustrating at the moment (his department is kept understaffed by budgetary constraints). In other respects he enjoys his job, finding it challenging, interesting and exciting. There is no significant history.

Blood pressure: 155/108. Six months ago he had a blood test - his fasting cholesterol level was 7.2mmol/l. His brother, five years older, had a triple heart by-pass operation three years ago, following a severe attack of angina. His coronary artery was found to be substantially blocked, and his cholesterol levels were found to be extremely high (fasting cholesterol 11.4mmol/l)

On palpation of his chest, there is a tender point on the rib cage about one and a half inches superior to the left nipple. There are no tender points on the Pericardium channel on the arm. He has a few broken blood vessels showing on the inside of the ankles.

Tongue: slightly mauve colour to body; dirty, powdery coating; slight distended and purply sub-lingual veins.

Pulse: slippery/wiry and rapid.

Diagnosis:

(a) Obstruction of the chest-Qi (patterns of congealed heart blood)

Signs and symptoms that inform my answer:

  1. The patient has chest pain at present.
  2. He had a sharp stabbing pain in the upper left chest above the nipple a few days ago, the pain was severe, radiating down the pericardium channel of the left arm to the elbow.
  3. There is palpation in his chest with a tender point on the rib cage about one and a half inches superior to the left nipple
  4. Tongue: Slightly mauve colour to the body; Purple sub-lingual veins.
  5. Pulse: Slippery/Wiry

Signs and symptoms that I can not reconcile:

  1. The patient has been experiencing a mild pricking pain in the same area.
  2. He is worried, anxious, stress, tired.
  3. He has experienced dizziness over the last few months.
  4. Tongue: Dirty, powdery coating, distended

Aetiology:

  1. Age: Deficiency of kidneys Qi. The Qi of kidneys are thus the "Root of body Qi", it will decrease after 45-50 years old.
    1. He is 54. (over 45-50 years old)
    2. Pulse: wiry and rapid
  2. Diet: Dampness Distressing the Spleen. Irregularity in quantity or quality of food, or in time of eating, can disrupt the bodys harmony. Insufficient food, lack of food, too much beer or wine; can mean that insufficient raw material reaches the spleen. It leads to a deficient Qi of spleen which is result in the dampness distressing.
    1. He has always enjoyed a few pints of beer (sometimes more than few) and becomes easily irritated.
    2. Tongue: powdery coating, dirty, slight distended
    3. Pulse: Slippery/wiry
    4. Genetics: His brother suffered the cardiovascular disease and high cholesterol 11.4mmol/l
    5. His Blood Test: High Cholesterol 7.2mmol/l
    6. His Blood Pressure is High 155/108mmHg
  3. Emotion: Constrained in Liver Qi. The seven emotional excesses or insufficiency over a long period of time, or when it arises very suddenly with great force, acts on the Liver Qi which results in the constrained Liver Qi.
    1. He is worried and anxious.
    2. The pain is often worse during stressful meetings.
    3. His working environment is very frustrating.
    4. Pulse: Slippery
  4. Excessive Labour: Deficient in spleen Qi (Deficient in Spleen Yang as well). Excessive labour, can strain the spleens ability to produce the Qi, leading to Deficiency of spleen Qi (spleen yang).
    1. The onset has been gradual and came on during a particularly busy time at work.
    2. It is often worse when he is tired.
    3. He has experienced dizziness in the morning.
    4. Tongue: slight distended

Pathology:

  • Obstruction of the Chest Qi is related with the Heart, Liver, Spleen, Kidneys organs.
  • The factor of pathology of Obstruction of the Chest Qi is deficiency of Qi; Blood Stasis; stagnation of Qi, Phlegm (it produces from Dampness)
  • According to the WM, this belong the abbreviation of coronary atherosclerotic heart disease. The risk of factors of the disease is hypertension, hyperlipemia, over drinking beer or wine.
  • Naturally kidney Qi is getting weak after 45 years old. The kidney is root of Qi.
  • The deficiency of the spleen Qi is responsible to transform food into Qi and result in dampness, causing Qi movement.
  • The stagnant liver Qi is the result of disturbed Qi movement from whole organs. The Qi is obstruct, the blood will following to be obstructed.
  • "The heart rules the blood and blood vessels"; Insufficient heart Qi could not move the blood in the chest which precedes and accompanies the pattern of congealed heart blood.
  • Finally, Qi and blood obstruct the heart and vessels in the chest.

Treatment principle

Promoting blood circulation for removing blood stasis, regulating Qi - flowing to activating stagnancy.

Prescription

  • Gualou xieba guizi decoction
  • Snakegourd peel: regulating Qi - flowing
  • Longstamen onion bulb: eliminating phlegm and resolving turbidity
  • Cassia twig: yang for activating Qi - flowing
  • Safflower: promoting blood circulation
  • Danshen root: enriches blood and improve circulation

Treatment plan

  • Symptomatic treatment in acute condition
  • Radical treatment in chronic case
  • This is acute an condition which is promoting blood circulation for removing blood stasis, regulating Qi - flowing for activating stagnancy
  • 3 months later, the treatment is mainly invigorating spleen and kidney.

Advice

  • Having a rest without any sport activity and labour for one month, then the patient can gradually start walking, increasing exercise slowly.
  • Keeping warm and a happy mood.
  • Eating regularly without fatty or oily food, lower salt. Don't drink too much of beer; wine; coffee, slowly eating small amount of food. Taking more fruit and salad.
  • Going to the toilet regularly, keeping bowel movement every day.
  • Taking herbal medicine twice a day.
  • Keeping good life style, not going to bed late and sleep 6-8 hours every day.

Phlegm and cholesterol

  • Common point: they both could cause cardiovascular disease.
  • WM and TCM comparison of cholesterol: Lipoprotein is of turbid phlegm in blood and cessels.
  • Exogenous is diet, heart disease, liver problem and spleen disorder.
  • Endogenous is genetics or kidney disorder.
  • Types of patterns of high cholesterol.
  • Damp phlegm
  • Blood stasis
  • Deficiency of spleen Qi
  • Stagnation of liver Qi
  • Deficiency of kidney Qi
  • There is a relation between phlegm and cholesterol: phlegm can cause the changing of cholesterol in the blood if the cholesterol is high, there is phlegm in the body.