Interstitial lung fibrosis medical case

  Qin XX, male, 68 years old Initial diagnosis (March 1, 2011): Three years ago, the patient developed dyspnea, panic attacks, shortness of breath with no apparent cause, which was aggravated after activity or going upstairs. He was treated with anti-inflammatory, symptomatic, and supportive treatments, but the results were not good, so he was advised to seek Chinese medicine treatment at a Chinese medicine hospital. He was admitted to our hospital today. His symptoms: dyspnea, shortness of breath, aggravated by activity, chest tightness, fatigue, poor sleep, dullness, diaphoresis, dark red tongue with little moss, and fine pulse. Physical examination: T36.8℃ P90 times/min R20 times/min BP130/80mmHg, symmetrical thorax, coarse breath sounds in both lungs, popping sounds can be heard at the base of both lungs, mainly in the left lung, low and distant heart sounds, heart rate 90 times/min, rhythmical, remaining (-), chest CT: interstitial fibrosis, pulmonary function: restrictive ventilatory dysfunction, blood gas analysis: suggesting type I respiratory failure (mild). Blood count: normal. Western medicine diagnosis: interstitial fibrosis of lung; Chinese medicine diagnosis: asthma (lung spleen qi deficiency, blood stagnation). 20g raw oyster 20g fowl’s nest 10g mucuna pruriens 10g decoction in water, one dose a day. The above prescription was followed by 7 doses. After 7 days of sedation with 5% GS 250ml + 30ml of ginseng and 5% GS 250ml + 30ml of danshen, the patient was discharged.  This case belongs to “asthma evidence” in TCM. In Western medicine, it is interstitial lung fibrosis. In TCM, the evidence belongs to deficiency of both qi and yin, and stagnation of blood vessels. If the lung is deficient in qi, there will be difficulty in breathing, qi weakness and shortness of breath. If the lung is deficient in qi, the lung will have difficulty in breathing, and if the lung is deficient in qi, the lung will have weakness and shortness of breath. Therefore, the treatment must take into account both the symptoms and the root cause. In the stable stage, we should benefit the Qi and nourish the Yin, invigorate the Blood and open the Blood vessels, focusing on the Lung, Spleen, Heart and Kidney.