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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