Record of Hospitalization
Name:
Mr. W. Sex: male
Age:
42
Nationality: Ireland
Marital
status: married
Date of
admission: Feb 4, 2006
Date of
record: Feb 4, 2006
Narrator of medical history: patient himself
Major
complaint:
Increased urinary frequency, strong prostate pains, painful urination. These have
been lasting for 13 years constantly.
The
medical history:
The
patient had the symptoms above 13years ago, especially after a long-time
job, but he didn¡¯t pay special attention. Consequently, the symptom was more
serious. He had experienced the western treatment for 2 months in his local
country, but no special improvement. In the September, 2005, he went to
Xiang Ya Hospital, Chang Sha city, Hu Nan province, to try
Chinese-Western-combined treatments and acupuncture, massage treatments, but
still no improvement. Now, the patient has the symptom of yellowish urinary,
burning pain in the urethra, perineum-ache, waist-ache and distending pain
in his lower abdomen, cold-pain feeling in the lower abdomen, loss of sexual
function, hypodynamia, without headache and dizziness, unclear vision,
slightly tinnitus in his ears, snuffle, baldness, constant cold-feeling on
his back, dry and bitter mouth and with the desire for warm water, good
appetite, easily-hungry but eat little, easily wake-up. He sometimes has
difficulty in bowel movement and the feeling of weakness after that.
Other
diseases:
He had
been suffering from the disease of lupus for 8 years. After so
many kinds of western medicines, he began to suffer the pain in all his
body-joints. He also suffered from rhinitis and took twice operations for
the nasal cavity.
Personal history:
He was
born in Ireland , has been to America and Chang Sha city, china, for
treatment. No habit of
smoking and, no other bad habit, his living condition is quite good. He got
married at 28, and his wife is quite healthy.
History
of his family:
The
parents of this patient are healthy, no other special disease.
Physical examination:
His
growth and nutrition are good, clear mind, cooperate with us, expression is
normal, no yellowish stain on his skin sclera, no blood point and tetter,
voice is loud enough, shortness of breath, white and damp tongue coating,
weak pulse, head and five sense organs are normal, no hyperemia in the
throat, no monstrosity in his vertebral column and four limbs, but there are
clear pressing-pains in his vertebral column and articutio sacralis. No edema
in his pubes part, dampness in this part, but peculiar smell, the doctor can
feel the hardness of his prostate.
Diagnostic Gist:
According to the theories of TCM and the symptoms above, we can diagnose the
disease as stranguria, which is because of deficiency of the kidney.
Differential Diagnosis:
The
main symptom is the frequency of urination, prostate pains and pain
in urination, which have been out breaking constantly for 13 years. This
disease is in the category of stranguria, which is different from ¡°dribbling
block¡±. The symbol of the latter is also urinary abnormity, but the symptom
of the latter does not conclude the frequency of urination and the pain in
stranguria. According to the analysis above, we can conclude that the
disease is chronic protatitis.
Treatment
plan:
1.
internal
medicine tending routine
2.
second grade
tending
3.
low-fat and
low-salt diet
4.
The herbal tea
is for warming and invigorating kidney-yang, invigorating the circulation of blood and removing dampness by diuresis.
February 5, 2006.
The
symptoms of increased-urinary-frequency, prostate pains, urodynia are
slightly better, soreness of the waist and knees, general lassitude, blurred
vision, general body pains, especially the pain in his vertebral column and
knee-joints is obvious, slight loss of hair, tinnitus, snuffle, cold sense
on the back, having problem of breathing in the night (he has been using the
respirator for 3 years), weakness after bowel movement, feel worse after
being tired.
Dr. Yang and Dr. Li
Feb 6,
2006.
He says
he obviously feels better after yesterday¡¯s treatment. He urinated 4 times
last night, but the urodynia disappeared, slept well, and energetic, the
soreness of muscles and body-joints reduced, and only slight pains left.
Leonurus 20g, salvia root 30g, peach kernel 10g, etc.
Dr. Li
Feb 8,
2006.
The
patient says he urinated 3 times last night, no precipitation urination, but
the abdomen near the prostate was still painful, much better than yesterday.
The aching pains of his general body was reduced.
His
rectum was painful when defecating and he felt weak after the bowel movement,
his nerve system is normal.
Leonurus 20g, salvia root
30g, peach kernel 10g, etc.
Dr. Li
Feb 10,
2006.
He says
urodynia appeared again, and he wanted to urinate all the time, the abdomen
near the prostate was obviously painful, but he felt nothing discomfort when
urinating. The aching pains of his general body was reduced more. The pain
around his rectum was slightly reduced. He says he is recovered by about
20%.
dioscorea root 10g,
cooked rehmannia
root 10g, Poria 10g, etc.
Pediluvium formula:
Prepared aconite main tuber
10g, cinnamom twig 30g, tangkuei 20g, etc.
Dr. Li
Feb 12,
2006.
The
patient says his prostate was still painful, but was much better. He slept
well for 4¡ª5 hours last night. The pains of his knee-joints, neck, back and articulatio sacralis were much
reduced. Appetite was good. His mouth was
bitter, but not dry. He says the pains of prostate are reduced by more than
20%, and that of his general body are reduced by about 40%.
dioscorea root 10g,
cooked rehmannia
root 10g, Poria 10g, etc.
Dr. Li
Feb 15,
2006.
He says
he only slept 4 hours. He has a little bit
diarrhea, but no obvious discomfort. The dampness and cold-pains in his
prostate before urinary was reduced a little. The pains in his general body
was much reduced. Appetite was good, mouth wasn¡¯t dry, he says the pain in
his prostate are reduced 40%, and pains of his general body are reduced
40% to 60%.
dioscorea root 10g,
cooked rehmannia
root 10g, Poria 10g, etc.
Dr. Li
Feb 17,
2006.
He says
he slept for 6 hours last night. He only urinated one time after he waked up
in the 6:00, the feeling of coldness and dampness in his
lower abdomen was still obvious. He felt a little
bit weak. Appetite is good.
dioscorea root 10g,
cooked rehmannia
root 10g, Poria 10g, etc.
Dr. Li
Feb 19, 2006.
He says he slept 7 hours last night.
He did not wake up for urination after he fell asleep. The feeling of
coldness and dampness in his lower abdomen was much reduced by about 70%.
dioscorea root 10g,
cooked rehmannia
root 10g, Poria 10g, etc.
Dr. Li
Feb 21, 2006.
Today the patient is very well. He
didn¡¯t urinate last night. His lower abdomen was a little bit cold-pain. He
feels energetic today.
Feb 22, 2006.
He says his prostate was worse from
yesterday afternoon. He felt his urination was frequent and urgent. He
couldn¡¯t sleep well.
dioscorea root 10g,
cooked rehmannia
root 10g, Poria 10g, etc.
Dr. Li
Feb 23, 2006.
He is much better than yesterday,
the pains are reduced but he can¡¯t sleep well, because he urinated 4 times
last night. He felt distension in his prostate before urination. There are
only slight pains in his general body.
dioscorea root 10g,
cooked rehmannia
root 10g, Poria 10g, etc.
Dr. Li
Feb 25, 2006.
He says his prostate is much better
than the last 2 days. He could sleep well for 7 hours. But he still feels a
little bit painful after urination.
dioscorea root 10g,
cooked rehmannia
root 10g, Poria 10g, etc.
Dr. Li
Feb 27, 2006.
He says there is no change in his
lower abdomen, he could sleep well. He slept 7 hours last night. He says he
has been recovered about 60%.
dioscorea root 10g,
cooked rehmannia
root 10g, Poria 10g, etc.
Pediluvium formula:
cinnamom twig 30g,
prepared aconite main tuber 10g, mugwort leaf 30g, etc.
Dr. Li
So after two weeks treatment, his prostate
pains have been reduced 60%, while his strong prostate pains have lasted 13
years.
