Integrative Case Study in Respiratory Diseases

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A 25 year-old male reports a life-long history of upper respiratory tract infections which occur about twice a year. Three weeks ago, he came down with the “flu,” with coughing of yellowish-green and difficult to expectorate sputum, fever and chills, shortness of breath, and slight chest pain. He saw a biomedical physician who diagnosed acute asthmatic bronchitis and prescribed a course of Amoxicillin for 10 days and a metered dose Albuterol inhaler, 2 puffs every 4 hours for a week. He stopped taking the inhaler after 4 days because he seemed to be getting palpitations, nervousness, and sleeplessness from taking it; besides, he was no longer short of breath. He did complete the course of Amoxicillin. He smokes marijuana daily and consumes about 3-4 beers nightly. He denies tobacco use. He has a steady diet of fast food and particularly enjoys very spicy Mexican food.

The cough has decreased gradually and the sputum has gradually become lighter in color; however he is still coughing. The cough is most prominent in the morning and after meals. Although there is no longer any yellow sputum, there is now a copious amount of whitish-grey sputum throughout the day. He also reports fatigue and loose stools since taking the antibiotic, as well as slight nausea and decreased appetite. His tongue is pale, tooth marked, and coated with a thick slimy white fur. His pulse is soft (Ru Mai).

Biomedical Examination

Upon auscultation, there are some slight wheezes and faint crackles. He does not appear short of breath at rest. His blood pressure is 115/62 and his pulse rate is 70. His respiratory rate is 15/min. His temperature is 98.1F.

1. TCM name. Explain (etiology, general facts, prognosis)

Based on the signs, symptoms and his history,...

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