病 案
TCM Case:Cough
Mr Wang,male,age 60
Main complaint:Recurrent chronic cough and shortness of breath for over 30 years with a severe relapse in the last 7 days.
Medical History:The patient suffered from chronic cough1) for more than 30 years，and he also had hypertension for 20 years.He caught a cold 7 days prior which triggered2) cough and panting with sticky，yellow and fish-smelling sputum which was difficult to expectorate.The patient also felt distending pain and heat sensation in the chest for over a week
Presenting symptoms:Cough with yellow and excessive sputum，panting，oppression and heat sensation in the chest，flushed face，profuse sweating，dry throat，thirst with desire for cold drinking，yellow urine，constipation，red tongue with yellow coating and a slippery and rapid pulse.
Physical Examination:Temperature:37℃；pulse:80 bpm；respiration:22 bpm；blood pressure:140 mmHg/85 mmHg(18.7 kPa/11.3kPa).The patient showed an active and conscious mind and was cooperative.The skin and sclera were non-icteric3).No significant lymph nodes were enlarged.Scattered rhonchi and moist rales were heard at the base of the lung.There was no enlargement of the heart and there was a regular rhythm.No heart murmur was heard.The liver and spleen were not palpable.No percussion pain4) over the kidney area.
Other Medical Test Results:
Blood Routine Test:WBC 12.0×109/L
Uine routine test:Normal
Chest X-ray:Thickened and disarranged lung markings which are netshaped，cord-like or spotted plaques.
Pattern Differentiation
Sticky smelly profuse phlegm from the lung as well as the yellow tongue coating are symptoms and signs which show that the cough in this case is due to phlegm-heat obstructing the lung qi.This phlegm-heat retention in the lung is causing failure of lung qi to perform its natural function of descending and opening manifesting as cough with massive sticky and yellow sputum.The symptoms of heat sensation and oppression in the chest are demonstrating that there is internal excessive heat retention in the chest.This heat is also causing the internal fluids to transform in thick phlegm which is difficult to expectorate giving it a strong fishy smell.This heat in the lung also burns up the natural body fluids which causes dryness and thirst with desire for cold drinks.If we further observe the red tongue with yellow coating as well as the slippery and rapid pulse we can confirm the internal retention of excessive phlegm-heat.
Diagnosis
TCM Diagnosis:Cough due to phlegm-heat obstructing the lung
Western Medicine Diagnosis:Chronic bronchitis with acute recurrence
Treatment
We need to treat this cough according to the presenting pattern.
Principles:
·Clear lung heat
·Dissolve phlegm and relieve panting
Formula：Qīng Jīn Huà Tán Tāng（Metal-Clearing and Phlegm-Transforming Decoction）recorded in General Guideline of Formulas（Tǒng Zhǐ Fāng，统旨方）
注释：
1）bronchitis 支气管炎
2）trigger 引起，触发，开动
3）icteric 黄疸的
4）percussion pain叩击痛
Case discussion of pneumonia（病案讨论：肺炎）
In the Doctor’s Office
Chief Resident:Your attention，please.The morning meeting begins now.Today Chief Physician Wang is going to give us a teaching round.To begin with，let’s hear the report presented by the Physician on Call first.
住院总医师：请注意，晨会开始。今天由王主任医师主持教学查房。首先请值班医生作交班报告。
Physician on Call:I was on call last night and nothing special happened except a new case.Here I’ll report the new case.The new patient is bed 1，a 30-year-old man.He was hospitalized at ten yesterday night because of fever，cough，and chest pain.After being febrile for 5 days，he failed to respond to amikacin given by a local hospital.Then he was transferred to our hospital with the diagnosis of pneumonia.He’s got a little better this morning，and the oral temperature is 38℃.That’s over.
值班医师：昨晚我值班，收治了一位新病人，其余病人无特殊情况。新病人在1床，男性，30岁，因为发热、咳嗽、胸痛，于昨晚10时收治入院。病人发热已有5d，在当地医院用阿米卡星针剂静脉治疗无效，以肺炎转入我院治疗。今天早上情况有所好转，口温38℃。报告完毕。
Chief Resident：Well，let’s have the new case as our topic today.Who is the intern in charge of the bed？（好，我们今天讨论的病例就是这个新病人。哪位实习医生负责这个床位？）
Intern A:It’s me.
Chief Resident:Now，Dr.Shi，please give us a presentation of the history.
Intern A:This 30-year-old man was admitted because of fever，cough and chest pain for five days.He had a cold a week before admission.Five days ago he began to have cough，yellow sputum and chest pain accomplished by fever with the highest temperature rising to 39℃.He was admitted to a local hospital where the chest X-ray reported left-lower-lobe pneumonia and he failed to respond to amikacin，so he was transferred to our hospital with the diagnosis of pneumonia.There was no history of recurrent respiratory tract infections or aspiration.And he denied any exposure to tuberculosis，asbestos，or other industrial dusts.
On admission，the left lower posterior lung showed moist rales at the end of inspiration on auscultation.The peripheral oxygen saturation was 98 percent while the patient was breating ambient air.His white-cell count was 11.2×109/L，N 80.2%，L 13.2%.The chest X-ray reviewed showed no significant changes compared with the previous one.Mainly that’s all.
实习医师甲：这位30岁男性患者因为发热、咳嗽、胸痛5 d入院。病人1周前患感冒，5d前出现咳嗽、咯黄痰及胸痛，伴发热，体温最高达到39℃。于当地医院住院，查胸片示左下肺炎症，静脉用阿米卡星针剂无效，以肺炎转入我院治疗。病人既往无反复呼吸道感染或吸入史，否认结核接触史，否认石棉或工业粉尘暴露史。
入院查体：左下肺闻及吸气相湿啰音。呼吸室内空气时外周血氧饱和度为98%。血白细胞计数为11.2×109/L，中性粒细胞80.2%，淋巴细胞13.2%。复查胸片提示与前片比较无明显改变。报告完毕。
Chief Physician:Good.Your presentation is quite clear，but there’s a few questions.Did the patient traveled recently?
Intern A:Sorry，I failed to ask it.
Chief Physician：You know，uncomplicated though it seems，we might feel confused about the diagnosis，especially if antibiotics（抗生素）failed to have effects.So receiving a patient with fever，we should particularly focus on the history which often contains the origin of the disease.What about his past history？
Intern A:He was in good health until this onset.
Chief Physician:Did he have any other complains except what you have mentioned,say,bellyache,headache,or vomiting?
Intern A:No.he mainly complained about fever，cough，and chest pain.
Chief Physician:Then anything special about his sputum?
Intern A:Oh，I failed to ask the details about it.
Chief Physician:That’s OK.But please pay attention to it later.Has ECG been done yet?
Intern A：Yes.It reported sinus tachycardia with a bit ventricular premature beats.And Holter has been ordered.（结果提示窦性心动过速，有一些室性期前收缩。动态心电图已经预约）
Chief Physician：Oh，premature beat.Do keep a close eye on it.What about myocardial enzymes？（应该特别注意期前收缩。心肌酶谱怎么样？）
Intern A：CK-MB，myoglobin，and troponin T（TnT）are normal.（肌酸激酶、肌红蛋白和肌钙蛋白T都正常）
Chief Physician：Good.But we should still review them and pay attention to Holter results in case of cardiac complications such as ventricular tachycardia which although not frequently，may cause lethal results.Now let’s have a look at the patient.（不过我们仍然需要复查心肌酶谱，并注意动态心电图的结果，以防出现心脏病并发症，如室性心动过速。尽管不多见，但是一旦出现室性心动过速，后果将是致命的。我们去病房看看病人吧。）
Intern A:Yes.Let’s go to the ward.
In the Ward
Chief Resident：Hello，Mr.Zhang.This is our Chief Physician（主任医师），Professor Wang，and that’s Dr.Guan，the Attending Physician（主治医师）.I’m Dr.Xie，by the way.(https://www.daowen.com)
Patient:Hello，doctors.
Chief Physician:How are you feeling now，Mr.Zhang?
Patient:I’m still having fever，cough and chest pain.
Chief Physician:Do you have any sputum?
Patient:Quite a lot，and it’s yellow.
Chief Physician:Have you noticed any blood or smell in your sputum?
Patient：No.I only found it quite glutinous（黏的）and purulent（脓的）.
Chief Physician:When does your temperature get the highest?
Patient:Er，usually at night，and it often goes down in the morning，so I’m feeling not bad while talking with you.
Chief Physician:Did you have any medicine at home?
Patient:Yes，I had an asprin(ASP)at the beginning and my fever dropped.However，it went up to 39℃ after hours.So I went to see the doctor.
Chief Physician:Have you ever been to another city or touching febrile patients recently?
Patient:No.
Chief Physician:OK.Now could we do an examination for you?
Patient:Sure.
Chief Physician:Dr.Xi,could you please do the examination?
Intern B:All right.
(Intern B is examining the patient.)
Intern B:My examination is as follows:the oral temperature is 37.4 ℃,the pulse rate is 98 per minute，and the respiratory rate is 24 breaths per minute.The blood pressure is 120mmHg/70 mmHg(16 kPa/9.3 kPa).Nothing abnormal with the head and the eyes.The neck feels soft.No three depression sign，thyroid enlargement，or jugular varicosity.The thorax has no tenderness and moist rales were heard at the left lung base.The heart rate is 100 beats per minute(bpm)with no arrhythmia except three premature beats per minute.The abdomen feels soft with no tenderness or rebound tenderness.Murphy’s sign is negative and nothing special in neurological examination.
实习医师乙：体检结果如下：口温37.4℃，脉搏98次/min，呼吸24次/min，血压120mmHg/70mmHg（16 kPa/9.3 kPa）。头部、眼部无异常。颈软，三凹征阴性，甲状腺无肿大，颈静脉无怒张。胸廓无压痛，左下肺闻及湿啰音。心率100次/min，律尚齐，闻及期前收缩3次/min。腹软，无压痛及反跳痛。Murphy征阴性。神经系统检查无异常。
Chief Physician:OK.Your job is pretty thorough.What I should replenish is that bronchial breath sounds can be heard in left lower posterior lung zone.All right.Thank you for your cooperation，guy.See you.
Patient:That’s OK.Bye.
In the Doctor’s Office
Chief Physician:Now，Dr.Shi，what’s your diagnosis of the case?And what’s your gist for the diagnosis?
Intern A:I think the patient suffers from pneumonia.The gist for diagnosis include fever，cough with yellow sputum，chest pain，moist rales，and elevated blood white-cell count.
实习医师甲：我认为这个病人患了肺炎，诊断依据包括发热、咳嗽伴黄痰、胸痛、湿性啰音和白细胞计数升高。
Chief Physician:Anything else?Dr.Xie，what’s your opinion?
Chief Resident:The usual standard for the diagnosis of pneumonia is chest radiography，which，however，is not 100% sensitive.It is important to exclude noninfectious causes of pulmonary infiltrates when evaluating a patient who presents with possible pneumonia.We have reviewed the chest radiograph which showed focal consolidation typical of pneumonia in the left lobe.The diagnosis of pneumonia has been made by chest radiography combined with clinical manifestation.
住院总医师：肺炎的诊断标准应依据影像学资料，然而，其敏感度不是绝对的。诊断表现为肺炎特征的病人时，排除非感染性的肺部浸润性病变很重要。通过复查胸片，发现左下肺叶实变且具有典型的肺炎影像学特征，结合其临床表现，我们做出了肺炎的诊断。
Chief Physician:Right.We should differentiate pneumonia with other diseases such as pulmonary tuberculosis,lung cancer,lung abscess,pulmonary embolism，and noninfectious causes of pulmonary infiltrates，which all lack clinical evidence in this patient.Now let us talk something about pneumonia，shall we?Pneumonia is an infection of the lungs.Many different organisms can be the cause，including bacteria，viruses，and fungi.Pneumonia can range from mild to severe，and can even be deadly.The severity depends on the type of organism causing pneumonia，as well as your age and underlying health.Bacteria tend to be the most serious and，in adults，the most common cause of pneumonia.Respiratory viruses are the most common reasons of pneumonia in young children，peaking between the ages of 2 to 3.By school age，mycoplasma becomes more usual.In some people，particularly the elderly and those who are debilitated，bacterial pneumonia may follow influenza of even a common cold.Pneumonia can be broadly categorized as community-acquired or hospitalacquired(nosocomial)types.What are the most common microorganisms resulting in community-acquired pneumonia(CAP)?Dr.Zhu?And what are the clinical characteristics?
主任医师：正确。我们还应当与肺结核、肺癌、肺脓肿、肺栓塞以及非感染性的肺部浸润性病变进行鉴别诊断，这些疾病在该病人处均缺乏依据。现在让我们了解一下有关肺炎的一些情况吧。肺炎是肺的一种感染，致病因素可以是多种病原体，包括细菌、病毒和真菌。肺炎的严重程度为从轻度到重度，严重程度下可以致命。感染的严重程度取决于致病的病原体、病人年龄及健康状况等因素。成年人感染细菌性肺炎往往是最常见的，可导致严重的后果。对于2~3岁的儿童来说，呼吸道病毒是引起肺炎的常见致病因素。在学龄儿童中，支原体肺炎更为常见。在一些人群，特别是在老年人及虚弱病人中，流感，甚至普通感冒后常会导致细菌性肺炎。肺炎可大致可划分为社区获得性肺炎与医院获得性肺炎2大类。朱医生，最常见的社区获得性肺炎（CAP）的病原体有哪些？说说其临床特点。
Resident:The most common pneumonia-causing bacterium of CAP is Streptococcus pneumonia or Pneumococcus,besides,Mycoplasma pneumonias is another common cause of community-acquired pneumonia.Classic symptoms of Pneumococcal pneumonia include chills，followed by fever，dyspnea，and the production of rusty or mucoid sputum or both.Pleuritic chest pain and tachypnea may develop.Extrapulmonary symptoms such as headache，nausea，vomiting，and abdominal distention may occur.In the classic form of Mycoplasma infection，patients present with constitutional symptoms，and the infection progress from the upper to the lower respiratory tract.Cough，fever，malaise，headache,and sore throat are major clinical findings in Mycoplasma pneumonia.Bullous myringitis is seen in about 5 percent of cases and，when present，suggests Myoplasma infection.There may not be significant physical findings.
住院医师：最常见的社区获得性肺炎的致病菌是肺炎链球菌。此外，支原体也是常见的病原体之一。肺炎链球菌肺炎的典型症状包括寒战，随后发热、呼吸困难、咳出铁锈色和（或）黏液痰。另外，还可能出现胸膜炎性胸痛、限制性呼吸（即由于胸膜炎性胸痛不能深呼吸）和呼吸加快。肺外症状包括头痛、恶心、呕吐与腹胀。典型的支原体肺炎病人会出现肺实变症状，感染从上呼吸道进展到下呼吸道。主要临床表现包括咳嗽、发热、乏力、头痛与咽痛。5%的病例可有大疱性鼓膜炎，一旦出现，即提示支原体感染。可无明显阳性体征。
Chief Physician:Pretty good!Dr.Guan,could you tell us the most common pneumonia-causing bacterium of nosocomial pneumonia and their clinical characteristics?
Attending Physician:OK.Most of all microorganisms causing nosocomial pneumonia were gram-negative bacilli，for example，Klebsiella pneumonia.The majority of these cases occur in persons over 40 years of age.And diabetes mellitus，chronic obstructive pulmonary disease and alcoholism are important predisposing conditions.Clinically，the presentation of Klebsiella pneumonia infection is acute,with dyspnea，cough，pleuritic pain，chills，and a temperature often higher than 39℃.The sputum is usually thick，bloody，and is produced in large volumes.Gross hemoptysis may occur.However，it should be stressed that Staphylococcus aureus(S.aureus)is among the most common causes of nosocomial pneumonia.S.aureus［including methicillin resistant S.aureus(MRSA)］frequently infects the lungs in association with intravascular catheter，endocarditis，and coma following head trauma or stroke.S.aureus pneumonia is suggested by the finding of pneumatocele on chest radiography and sometimes resulted in a significantly higher infectionassociated mortality rate，especially when the pathogen is resistant to several antibiotics.
主治医师：医院获得性肺炎的病原体大多为革兰氏阴性杆菌，肺炎克雷伯菌是其中之一。克雷伯菌肺炎大多数发生在40岁以上的人群中，糖尿病，慢性阻塞性肺病和酒精中毒是重要的易患因素。在临床上，克雷伯菌肺炎表现为急性咳嗽、呼吸困难、胸膜痛、寒战、体温往往高于39℃。痰液通常黏稠、带血、量较多，还可发生大量咯血。然而，应当指出金黄色葡萄球菌是医院获得性肺炎最常见的病原体之一。金黄色葡萄球菌［包括甲氧西林耐药金黄色葡萄球菌（MRSA）］经常与静脉留置导管感染、心内膜炎及创伤或卒中后昏迷有关。金黄色葡萄球菌肺炎病人的胸片可出现气囊肿，当对多种药物耐药时，金黄色葡萄球菌肺炎病人的死亡率明显升高。
Intern A:May I ask a question，Professor?What’s the pathogen of this patient?
Chief Physician:Interesting question!In fact，the etiology of CAP is unknown in many patients although some lab examinations are helpful to find out it.And it’s exactly a difficulty but a hot topic in clinical practice.Dr.Zhu,what lab examinations have you prescribed so far?
Resident：We have done cultures of blood and sputum，sputum examination for acid-fast bacilli，and test for cold agglutinins.（我们已经做了痰培养和血培养、痰抗酸杆菌试验及冷凝集试验。）
Chief Physician：I suggest tests of urine antigen for legionella spp.and Streptococcus pneumonia be prescribed.OK，let’s discuss the treatment.Dr.Guan，what’s the current antibiotic therapy？（我建议查尿样中军团菌及肺炎链球菌抗原。好，我们来谈论该病人的治疗。管医生，目前的抗生素治疗方案是什么？）
Attending Physician：As you have mentioned that the etiology of pneumonia is frequently unknown，we initiated with empirical antibiotic therapy，that is，amoxicillin/clavulanic acid plus levofloxacin intravenously.（正如您刚才所说，由于肺炎的病原体常常不明，因此我们采用经验性抗生素治疗，应用阿莫西林/克拉维酸钾联合左氧氟沙星静脉输注。）
Chief Physician:That’s OK.But antibiotics are to cure the infection if the pathogens are bacteria.While if it is caused by a virus，typical antibiotics may fail to be effective.In such cases，we should use antiviral medication.However，sometimes it is difficult to distinguish viral and bacterial pneumonia.Considering the patient’s personal data and history，I think Streptococcus pneumonia may be the pathogen，which may explain why he was insensitive to amikacin at the beginning.While a few lab examinations are needed for confirmation.Your empirical antibiotic therapy is in accordance with the current guidelines for the management of CAP by Chinese medical association.But I suggest keeping a close eye on his temperature and complete blood count(CBC)，and regulate the therapy if necessary.After all，the possibility of mixed infection of bacteria and virus can’t be neglected.Then my last question，who can tell us what are the complications of pneumonia?
主任医师：可以，不过如果是细菌性肺炎，应当用抗生素来治疗。但若是有病毒引起的，则抗生素治疗是无效的，有些病例需要使用抗病毒药物。然而，有时候很难区分是病毒感染还是细菌感染。这位病人的血液中中性粒细胞升高，提示细菌性肺炎，结合其个人资料及病史，我认为可能是肺炎链球菌感染，这也可以解释为什么他一开始对阿米卡星不敏感，不过还需一些实验室检查以确诊。你们的经验性治疗方案符合现行的我国CAP诊治指南，不过我认为应该密切注意病人的体温和全血细胞计数（CBC），必要时调整治疗方案。毕竟，我们不能忽略细菌和病毒混合感染的可能。我提最后一个问题，谁能说一下肺炎的并发症有哪些？
Intern A：My pleasure.The most common complications are respiratory failure，congestive heart failure（充血性心力衰竭），shock，pleurisy（胸膜炎），septicemia（败血症），empyema（脓胸），lung abscesses（肺脓肿），and so on.
Chief Physician:Pretty good!Finally let’s discuss the prevention of pneumonia.The latest guidelines for the management of CAP by Chinese medical association has ascertained the status of vaccination of influenza and Pneumococcus in reducing the morbidity and mortality of CAP.Therefore，people with pneumonia risk factors should be vaccinated，which also reflects the ideology of modern medicine.That is，better keep the devil at the door than turn him out of the house.All right，that’s all for today.Thank you all.
主任医师：相当不错！最后讨论一下肺炎的预防。最新的我国《CAP诊治指南》肯定了流感疫苗与肺炎链球菌疫苗可减少CAP的发病率及病死率。因此，具有肺炎危险因素者应当接受流感疫苗与肺炎链球菌疫苗的接种，这也是现代医学理念的体现，即“防重于治，治已病不如治未病”。好了，今天就到这里，谢谢你们！
Chief Resident:Thank you，Professor.
In the Ward(Seven Days Later)
Resident:Nice to see you.Mr.Zhang.You look perfect.How are you today?
Patient:Oh，great!Now I have no fever，and the cough and chest pain have been greatly alleviated.Could I go back home?
Attending Physician:Dr.Zhu，what about his CBC and chest X-ray(CXR)?
Resident:The white blood cell count has returned to normal.His temperature has been normal for three days.The CXR reported the lesion is improving，although the infiltration hasn’t been absorbed completely.And other lab tests including Holter showed nothing abnormal.
Attending Physician:The standard duration of treatment for most patients with CAP is 10 to 40 days.While I suggest the patient can switched to oral antibiotics in view of his current condition.(After checking the patient)Well,congratulations，guy.You can go home tomorrow but should continue the drugs and rest.Do follow up and review CXR after one or two weeks.
主治医师：大多数CAP 病人治疗的标准疗程是10~14d。然而根据病人目前的情况，我建议可以将抗生素改为口服。（检查过病人后）好吧，恭喜你，小伙子，明天你就可以出院了，不过还得继续吃药、休息，1~2周后一定要记得到门诊随访、复查胸片。
Patient:That’s great!Thanks a lot.
Attending Physician:You are welcome.I hope you’ll be yourself soon.