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Record of
Hospitalization
Name: Mr.
A Sex: male
Age:
43 Profession:
computer program designer
Nationality: Saudi
Arabia
Date of
hospitalization: June 15, 2006
Marital Status:
married
Major complaints:
The patient always
has the symptoms of polyphagia, polydipsia, polyuria and thirst for three years.
He also suffers back pains, and couldn¡¯t stretch freely.
He took an
examination at the local hospital and found that he had
hyperglycemia and high blood fat. He turns to TCM treatment because of the side
effect caused by western medicine. Pressing pains of the left kidney area.
Impotence. Dry and itching skin.
History of present illness:
The bowel
movement is normal. The pulse is fine and rapid. Whitish and greasy tongue
coating.
He has no
infectious
disease history of
tuberculosis, hepatitis and typhoid. No history of blood transfusion and
no allergy to any medicine.
Physical Examination:
Normal growth of her body and common nutrition level. Clear
consciousness and cooperative. No yellow stain of the skin sclera. No edema of
the
superficial lymph nodes. Normal growth of his head and five sense organs.
Symmetrical size of the pupillae. Sensitive to the light reflection. No
hyperaemia in the throat. No edema of the tonsil and
thyroid gland. Thoracic cage is symmetrical. Clear percussion sound. Normal
breath sound in the lungs. he heart rate are 74 times per minute. Normal rhythm
of the heart. The abdomen is flat and soft. No pressing pains and no rebound
tenderness. Pressing pains of the left kidney area. Normal intestinal gurgling
sound. No malformation of spinal column and limbs.
Diagnosis of Chinese Medicine : wasting-thirst (exuberant heat of lung and
stomach)
Diagnosis of Western Medicine: diabetes type
¢ò
and hyperlipaemia.
The treatment strategy: clearing away the stomach-heat, reduce fire, nourish yin
and boost qi. We use herbal tea combined with acupuncture and massage for his
treatment.
July 17, 2006
Good sleep at night. Slight dizziness. Three times night urination. Back pains.
July 18, 2006
Slight dizziness. Thirst and like drinking. The pulse is fine and rapid. Whitish
and thin tongue coating. Reddish tongue body.
white ginseng
10g£¬fresh
rehmannia root
20g£¬anemarrhena
root
15g£¬scrophularia
root
10g£¬
etc.
July 22, 2006
Reduced food intake in the recent days. So we add
atractylodes root
6g and
fresh rehmannia root
20g into the original formula.
July 26, 2006
His blood sugar becomes normal basically. Much food intake and drinking much
have been under control. The patient demands left hospital.
Doctor's advice after leaving hospital:
1.
Keep on doing daily
excise.
2.
Control the diet.
Avoid sugar and fat intake.
Continue
with the herbal tea to consolidate the treatment result.
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