Hospitalization Records
Name:
Fadi Sex: Male
Age:
31
Hospitalization No.: 0000893
Date
of admission:
November 17,
2006
Date
of hospital discharge:
February 1, 2007
Number
of Hospital admission days:
75 days.
Diagnosis of hospital admission:
TCM:
Bi-syndrome (impediment syndrome);
WM:
1.
Multiple
sclerosis; 2. Prolapsed of lumbar intervertebral disc.
Diagnosis of hospital discharge:
TCM:
Bi-syndrome (impediment syndrome);
WM:
1.
Multiple
sclerosis; 2. Prolapsed of lumbar intervertebral disc.
The patient,
Fadi, a 31-year-old male, has suffered from lower limb weakness and numbness for
five years accompanied by walking difficulties, trembling and urinary
incontinence for three years. He came in our hospital for treatment on November
17th, 2006. In 2001, the patient suddenly felt weakness on his lower
limb when he was playing football. At that time, he neither paid attention to
it, nor did any examination and treatment. But later on his disease condition
showed continual aggravation. Three months later, the sensation of numbness
began to develop from the lower limb to his toes. He then went to do examination
at a local clinic. The clinic gave him glucocorticoid drugs for orally taken
(cortisone), and his disease condition became a little better. Two years later,
the patient¡¯s lower limb began to tremble; he also had urinary incontinence
during the night and pain on his lumbar region. He went to check at the local
hospital, but the diagnosis was unclear. He continued taking cortisone orally
until now. Since the patient had this disease, his spirit is little bit worse;
he experiences bad sleep, but has a good appetite. He has urinary incontinence
during the sleep in the night time. His bowel movement is normal.
Procedures of hospital admission:
Since the
patient was admitted to our hospital, we gave him Chinese medicine to enrich the
liver and kidney, quicken the blood and free the channels. One dosage of the
Chinese medicine a day to be drunk twice, also acupuncture and massage combined
therapy once a day. The MRI examination from the First Hospital of Huaihua City
at November 22, 2006 showed: 1. L4, 5 level neck spinal cores are a little
bigger, so it is considered demyelination pathological changes. 2. L5/ S1 discs
intervertebral. After confirmed the diagnosis, we continue to give the patient
Chinese medicine, acupuncture, massage and traction combined therapies. The
patient¡¯s disease condition is better.
Condition of hospital discharging:
The patient
feels less lower limb weakness; the trembling is mitigated and he feels less
walking difficulties. He has obvious pain when pressing on lumbosacral portion.
He presents a good spirit and his appetite is good too. His sleep is nice. His
bowel movement and urination are normal. Slight red tongue, thin and white
tongue fur, fine and deep pulse.
Physical examination:
T 36.4¡æ£¬P
80bpm, R 20bpm, BP: 110/70mmHg. heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Doctor¡¯s advice after hospital discharge:
1.
Continue
Traditional Chinese medicine therapies;
2.
Avoid physical
work;
3.
Doing
regularly countercheck.
Records of Hospitalization
Name:
Fadi
Sex:
Male
Nationality:
Syrian Age:
31
Birth-place:
Syria
Profession:
Athlete
Marital status:
Unmarried Date
of Admission:
Nov. 17th, 2006
Onset
Season:
Spring
Date of
Report:
Nov. 17th,
2006
Complainer of history:
The patient
Reliability:
Reliable
Chief
complaint:
The patient has suffered from lower limb weakness and numbness for five years
accompanied by walking difficulties, trembling and urinary incontinence for
three years.
Present illness:
The patient
suddenly felt weakness on his lower limb when he was playing football five years
ago. At that time, he did not pay attention to it, but later on his disease
condition showed continual aggravation. After three months, the sensation of
numbness began to develop from the lower limb to his toes. He then went to do
examination at a local clinic. The clinic gave him glucocorticoid drugs for
orally taken (unknown specific details), and his disease condition became
better. Two years later, the patient¡¯s lower limb began to shake; he also had
urinary incontinence during the night and pain on his lumbar region. He went to
check at the local hospital, but the diagnosis was unclear. He continued taking
glucocorticoid drugs (cortisone) orally until now. Since the patient gets this
disease, his spirit is little bit worse; he experiences bad sleep, but had a
good appetite. His urination is normal during the daytime, but has urinary
incontinence during the night. He has used urethral catheter for three years.
His bowel movement is normal. Slight reddish tongue, thin and white tongue fur,
fine and deep pulse.
Past
history:
No history of typhoid, tuberculosis and hepatitis. No history of food or
medicine allergy. Seven years ago, he fractured his right forearm and did
internal fixation with steel plate. No history of transfusion. No history of
preventive vaccination provided.
Personal history:
He was born in Syria, living in a dry environment. No contact history of
schistosomiasis. He smokes about 20 cigarettes everyday during the five years.
No addiction to alcohol, or special food. He is calm temperament and cheerful.
Marital history:
Unmarried.
Family
history:
His parents still alive. No family history of special disease.
Physical examination:
T 36.4¡æ£¬P
80bpm, R 20bpm, BP: 110/70mmHg.
He is
mid-nourished, normally developed and has a clear mind. He is in a positive
position and cooperative in examination. His skin is moist. No jaundice in the
sclera. No superficial lymph-node enlargement. Bilateral pupils are round, equal
in size and sensitive to light. No thoracic deformity. The sound of breath is
bilaterally normal on auscultation. No respiratory rales or pleural friction
rubs, the heart border is not big. Heart beat is 80bpm. Cardiac rhythm is
regular. No pathological murmurs of heart on
auscultation. Abdomen is
flat and soft without tenderness or rebound tenderness. The lumbar region and
lower limb will see the special examination. Liver and spleen are not palpable.
Bowel sound is normal. No Spinal and
pelvic deformity or tenderness. Both upper limbs without deformity and normal
mobility, both lower extremities will see the special examination. The
development of the anus or genital was normal. Physiological reflex has
pathological features without elicited.
Special
examination:
The patient has suffered from lower limb weakness and difficulty on walking. He
can walk slowly but needs wall to help. He has a sensation of numbness sensation
from the inner side of the lower limb to the toes and often trembles. There is
one place has obvious tenderness between L4-5. His bilateral piriform muscle has
obvious tenderness and radiates to lower limb¡¯s toes. His ankle-joints are
stiffness. Straighten-leg raising test is (+), drawer test is (+). Knee tendon
is hyperreflexi, Klinefelter syndrome, Babinski syndrome (+).
First
diagnosis:
TCM diagnosis:
Bi-syndrome (impediment syndrome)
Symptom diagnosis:
Liver and
kidney asthenia; sinews and vessels stasis or obstruction.
WM
diagnosis:
1. Spinal
verve is under examination;
2. Prolapse
of lumbar intervertebral disc£¿
Dr. Yang qingzhi/ Dr. Dai Lei
November 17th, 2006
Supplementary
diagnosis: Multiple sclerosis.
Dr. Yang qingzhi/ Dr. Dai Lei
November 21st, 2006
First Medical Record
10:00
a.m. November 17th, 2006
Fadi, male,
has suffered from lower limb weakness and numbness for five years accompanied by
walking difficulties, trembling and urinary incontinence for three years. He
was picked up by our workers from Zhijiang Airport and transported to our
Huaihua Red Cross Hospital at November 17th, 2006.
Case characteristics:
1. The patient
has suffered from lower limb weakness and numbness for five years accompanied by
walking difficulties, trembling and urinary incontinence for three years.
2. The patient
suddenly felt weakness on his lower limb when he was playing football five years
ago. At that time, he did not pay attention to it, but later on his disease
condition showed continual aggravation. After three months, the sensation of
numbness began to develop from the lower limb to his toes. He then went to do
examination at a local clinic. The clinic gave him glucocorticoid drugs for
orally taken (unknown specific details), and his disease condition became
better. Two years later, the patient found his lower limb began to tremble; he
also had urinary incontinence during the night and pain on his lumbar region. He
went to check at the local hospital, but the diagnosis was unclear. He continued
taking glucocorticoid drugs (cortisone) orally until now. Since the patient gets
this disease, his spirit is little bit worse; he experiences bad sleep, but has
a good appetite. His urination is normal during the daytime, but has urinary
incontinence during the night. He has used urethral catheter for three years.
His bowel movement is normal. Slight reddish tongue, thin and white tongue fur,
fine and deep pulse.
3. T: 36.4¡æ£¬P:
80bpm, R: 20bpm, BP: 110/70mmHg.
4. He is
mid-nourished and normally developed. His mind is clear, chronic face mirroring
difficult condition, showing languor expression; He is in a positive position
and cooperative in examination.
5. No thoracic
deformity. Chest percussion noted resonance. Sound of breath was bilaterally
clear on auscultation. No pleural friction rubs. Heart border is not big. Heart
beat is 80bpm. Cardiac rhythm is regular.
6. The patient
has suffered from lower limb weakness and difficulty on walking. He can walk
slowly but need wall to help. He has numbness sensation from the inner side of
the lower limb to the toes and often trembles. There is one place has obvious
see tenderness between L4-5. His bilateral piriform muscle has obvious
tenderness and radiates to lower limb¡¯s toes. His ankle-joints are stiffness.
Straighten-leg raising test is (+), drawer test is (+). Knee tendon is
hyperreflexi, Klinefelter syndrome, Babinski syndrome (+).
7. Accessory
examination: Not provided yet.
Diagnostic basis
TCM:
The
patient has suffered from lower limb weakness and numbness for five years
accompanied by walking difficulties, trembling and urinary incontinence for
three years. Bi-symptom (Impediment syndrome), is caused by evil Qi, such as
wind, cold, damp and heat, etc, which blocked the channels and network vessels
or affected Qi-blood transportation. These lead to pain on limbs, sinews, bones,
joints, muscles and so on. It is a kind of disease that the critical ill
patients will have the symptoms of soreness, numbness or joints inhibited
bending and stretching, stiffness, swelling or deformity, etc. The uncritical
ill patients have the disease on the four limbs, joints or muscles, but the
critical one will have it in the Zang (five viscera). It is the basic
PathomeChanism of Bi-syndrome (impediment syndrome) that the evil Qi, such as
wind, cold, damp, heat, phlegm or stasis stagnated and accumulated in the limbs,
sinews, vessels, joints or muscles; or the channel vessel was blocked or
obstructed and caused pain if it was unopened. At the beginning of Bi-syndrome
(impediment syndrome), it is repletion if the evil of wind, cold, damp or heat
is obvious. A long period of Bi-syndrome will lead to consume and injury Qi-blood,
damage Zang-fu (bowels and viscera), and it is vacuity if insufficiency of the
liver and kidney. Lingering disease procedure, or not recovered for a long
period, is usually vacuity-repletion with miscellaneous pathoconditions of
phlegm-stasis mutually combined and liver-kidney depleted-vacuity.
Western medicine basis:
The patient has suffered from lower limb weakness and numbness for five years
accompanied by walking difficulties, trembling and urinary incontinence for
three years. The patient has suffered from lower limb weakness and difficulty on
walking. He can walk slowly but needs a wall to help. He has a sensation of
numbness from the inner side of the lower limb to the toes and often trembles.
There is one place has obvious tenderness between L4-5. His bilateral piriform
muscle has obvious tenderness and radiates to lower limb¡¯s toes. His
ankle-joints are stiffness. Straighten-leg raising test is (+), drawer test is
(+). Knee tendon is hyperreflexi, Klinefelter syndrome, Babinski syndrome (+).
Diagnostic differentiation£ºBi-syndrome
differentiated from Wei-syndrome:
Bi-syndrome
caused by the evil of wind, cold, damp or heat which flows into the interstices
of the flesh, the channel and network vessels and then blocked the sinews,
vessels and joints. First of all, the main point we have to differentiate pain
and no-pain from the two syndromes. Bi-syndrome is focused on the pain in the
joints. On the contrary, Wei-syndrome usually has no pain but weakness in the
body and limbs. Secondary, observe the movement obstruction of the limbs. Wei-syndrome
is characterized by weakness of movement, but Bi-syndrome is characterized by
pain, which affects the movement. These should be differentiated.
WM
differentiated from Rheumatoid arthritis:
Rheumatoid
arthritis indicated in clinical items: Stiffness in the morning time, at least
has one articular paining during the movement, or has tenderness; has swelling
in one articular soft tissue or has accumulated liquid. At least have one
articular swelling (the time interval won¡¯t excess three months of two articular
symptoms), symmetry articular swelling, and the position of the protruded bone,
the limbs bending and stretching, or subcutaneous nodules around the articular.
These should be differentiated.
First
diagnosis:
Bi-syndrome
(impediment syndrome)
Symptom diagnosis:
Liver and
kidney asthenia; sinews and vessels stasis or obstruction.
WM
diagnosis: 1.
Spinal verve
is under examination;
2.
Prolapsed of lumbar intervertebral disc?
Supplementary
diagnosis: Multiple sclerosis.
Dr. Yang qingzhi/ Dr. Dai Lei
November 22nd, 2006
Plan
of the treatment:
1. On routine
care of traditional Chinese internal medicine
2. On grade II
care
3. Nice food
4. Herbal tea:
Add or reduce Hidden Tiger Pill. The prescription: Shudi (Cooked rehmannia),
Duzhong (eucommia), Guiban (tortoise plastron), etc. One dosage a day and drink
by twice.
5. Massage
once a day
6. Acupuncture
once a day
7. Functional
training once a day
8. Have more
medical examinations if necessary
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date: 20th of November 2006
Time: 9:00 a.m.
The patient
still feels lower limb weakness, numbness and trembling, especially in the left
lower limb; it is accompanied by tenderness about the left side of L5/L4 to the
left lower limb. He has urinary incontinence and difficulties to stool. Dull red
tongue body, yellow tongue fur, string like and slippery pulse. In TCM, it is
insufficiency of the liver and kidney and damp-heat static obstruction. The
treatment is better to enrich the liver and kidney, dispel damp, transform
phlegm and free the network vessels. The prescription will be seen the temporary
doctor¡¯s advice. WM diagnosis is unclear at present. His examination records
from Syria are still on route. We will give him a diagnosis meeting when his
examination records arrive.
Dr. Yang
Qingzhi
Date:
23rd of November 2006
Time: 9:00 a.m.
The patient¡¯s
examination records from Syria have arrived. Yesterday morning, we brought the
materials to the MRI Department of the First People¡¯s Hospital of Huaihua City
and gave the patient a diagnosis meeting there. It was very hard to make a
definite diagnosis due to the poor quality of MRI films. Yesterday afternoon, we
brought the patient to the First people¡¯s Hospital to recheck his cervical
vertebra MRI and lumbar vertebra MRI. The confirmed diagnosis is: 1. Multiple
sclerosis; 2. L5/S1 lumbar intervertebral disc. Traditional Chinese Medicine
treatment mainly to supplement the liver and kidney, free the channels and
quicken the network vessels. The prescription is seen the temporary doctor¡¯s
advice.
Dr. Yang
Qingzhi
Date:
26th of November 2006
Time: 9:00 a.m.
The patient
says the pain of his lumbar and left lower limb is lighter. His lower limb has
more power than before and can be roused up about 70cm and the numbness
sensation is a little better, as well. Red tongue, yellow and dry tongue fur,
string like and slippery pulse. Take Lujiao (deerhorn glue) away but add Zhimu (anemarrhenae)
in to the former prescription. Continue the principle of clear heat and enrich
Yin.
Dr. Yang
Qingzhi
Date:
29th of November 2006
Time: 9:00 a.m.
The patient
says that the pain of his lower limb is lessening gradually day by day; the
sensation of numbness and trembling are turning better. It¡¯s mainly indicated on
his lower limb lack of strength, very hard to walk and urine out of control
during the night time. Dull and red tongue, yellow tongue fur, string like and
slippery pulse. The principle of the treatment is supplement the liver and
kidney, dispel damp, free the channels and quicken the network vessels. The
prescription is seen the temporary doctor¡¯s advice.
Dr. Yang
Qingzhi
Date:
3rd of December 2006
Time: 10:00 a.m.
The patient
says that his lower limb has more strength than before, the sensation of
numbness and trembling are reducing. The distending pain on his left lower limb
is gradually relieved. The movement of his ankle joints is more flexible than
before. Incontinence of urine during the night time, he needs to use urethral
catheters. His bowel movement is normal and usual diet and appetite. Slight
yellow tongue fur, string like and slippery pulse. No strength when repressing.
The treatment principle is mainly to supplement the liver and kidney, strengthen
sinew and bone, free the channels and quicken the network vessels. The
prescription is Shoudi (Cooked rehmannia), Guiban (tortoise plastron), Duzhong (eucommia),
etc. Five days.
Dr. Yang
Qingzhi
Date:
8th of December 2006
Time: 9:00 a.m.
The patient
says that the symptoms of weakness, numbness and trembling on his lower limb are
mitigated, but he still can not control his urine during the night time. Dull
red tongue, yellow tongue fur, string like pulse. No strength when repressing.
Five days.
Dr. Yang
Qingzhi
Date:
11th of December 2006
Time: 9:00 a.m.
The patient
says that the symptoms of weakness, numbness and trembling on his lower limb are
mitigated, but he still can not control his urine during the night time. No
aversion to cold. No fever. No headache or dizziness. No nausea or vomiting. He
presents with a good spirit. His sleep is good. His appetite is as usual. His
bowel movement and urination are normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The rest are good. Dull red tongue, thin and white tongue fur, string like
pulse. No strength when repressing hard. Continue the same treatment as above.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
14th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. His sleep is good. His appetite is as usual. His bowel movement and
urination are normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness; numbness and trembling on
his lower limb are mitigated a little bit, but he still can not control his
urine during the night time. Dull red tongue, thin and white tongue fur, fine,
deep and string like pulse. No strength when repressing hard. Continue the same
prescription as before. The prescription is Shoudi (Cooked rehmannia), Guiban
(tortoise plastron), Duzhong (eucommia), etc. One dosage a day and drink by
twice, 5 days.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
17th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. His sleep is good. His appetite is as usual. His bowel movement and
urination are normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness; numbness and trembling on
his lower limb are obviously relieved, but he still can not control his urine
during the night time. Dull red tongue, thin and white tongue fur, fine and deep
pulse. No strength when repressing hard. Continue use the same prescription.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
20th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. His sleep is good. His appetite is as usual. His bowel movement and
urination are normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness; numbness and trembling on
his lower limb are obviously relieved, but he still can not control his urine
during the night time. Dull red tongue, thin and white tongue fur, fine and deep
pulse. No strength when repressing hard. Continue use the same prescription. The
prescription is Shoudi (Cooked rehmannia), Guiban (tortoise plastron), Duzhong (eucommia),
etc. One dosage a day and drink by twice, 5 days.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
23rd of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. His sleep is good. His appetite is as usual. His bowel movement and
urination are normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness; numbness and trembling on
his lower limb are obviously relieved, but he still can not control his urine
during the night time. Dull red tongue, thin and white tongue fur, fine and deep
pulse. No strength when repressing hard. Continue use the same prescription.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
26th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. He presents with a good
spirit. His sleep is good. His bowel movement and urination are normal. Physical
examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness; numbness and trembling on
his lower limb are obviously relieved, but he still can not control his urine
during the night time. Dull red tongue, thin and white tongue fur, fine and deep
pulse. No strength when repressing hard. Continue use the same prescription. The
prescription is Shoudi (Cooked rehmannia), Guiban (tortoise plastron), Duzhong (eucommia),
etc. One dosage a day and drink by twice, 5 days.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
29th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. He presents with a good
spirit. His sleep and appetite are good. His bowel movement and urination are
normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness; numbness and trembling on
his lower limb are obviously relieved, but he still can not control his urine
during the night time. Dull red tongue, thin and white tongue fur, fine and deep
pulse. No strength when repressing hard. Continue use the same prescription.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
1st of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. He presents with a good
spirit. His sleep and appetite are good. His bowel movement and urination are
normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness; numbness and trembling on
his lower limb are obviously relieved, but he still can not control his urine
during the night time. Dull red tongue, thin and white tongue fur, fine and deep
pulse. No strength when repressing hard. Continue use the same prescription.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
4th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. He presents with a good
spirit. His sleep and appetite are good. His bowel movement and urination are
normal. No aversion to cold. No fever. No headache or dizziness. No nausea or
vomiting. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness; numbness and trembling on
his lower limb are obviously relieved, but he still can not control his urine
during the night time. Dull red tongue, thin and white tongue fur, fine and deep
pulse. No strength when repressing hard. Continue use the same prescription.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
7th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. He presents with a good
spirit. His sleep and appetite are good. His bowel movement and urination are
normal. No aversion to cold. No fever. No headache or dizziness. No nausea or
vomiting. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness and trembling on his lower
limb are obviously become less, but he still can not control his urine during
the night time. Dull red tongue, thin and white tongue fur, fine and deep pulse.
No strength when repressing hard. Continue use the same prescription. The
prescription is Shoudi (Cooked rehmannia), Guiban (tortoise plastron), Duzhong (eucommia),
etc. One dosage a day and drink by twice, 5 days.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
10th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. He presents with a good
spirit. His sleep and appetite are good. His bowel movement and urination are
normal. No aversion to cold. No fever. No headache or dizziness. No nausea or
vomiting. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness and trembling on his lower
limb are obviously relieved, but he still can not control his urine during the
night time. Dull red tongue, thin and white tongue fur, fine and deep pulse. The
prescription is Shoudi (Cooked rehmannia), Guiban (tortoise plastron), Duzhong (eucommia),
etc. One dosage a day and drink by twice, 5 days.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
14th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. He presents with a good
spirit. His sleep and appetite are good. His bowel movement and urination are
normal. No aversion to cold. No fever. No headache or dizziness. No nausea or
vomiting. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness and trembling on his lower
limb are obviously relieved, but he still can not control his urine during the
night time. Dull red tongue, thin and white tongue fur, fine and deep pulse.
Continue use the same prescription.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
18th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. His sleep and appetite are good. His bowel movement and urination are
normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness and trembling on his lower
limb are obviously relieved, but he still can not control his urine during the
night time. Dull red tongue, thin and white tongue fur, fine and deep pulse.
Continue use the same prescription. The prescription is Shoudi (Cooked rehmannia),
Guiban (tortoise plastron), Duzhong (eucommia), etc. One dosage a day and drink
by twice, 5 days.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
22nd of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. His sleep and appetite are good. His bowel movement and urination are
normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness and trembling on his lower
limb are obviously relieved, but he still can not control his urine during the
night time. Dull red tongue, thin and white tongue fur, fine and deep pulse.
Continue use the same prescription.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
26th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. His sleep and appetite are good. His bowel movement and urination are
normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness and trembling on his lower
limb are obviously relieved, but he still can not control his urine during the
night time. Dull red tongue, thin and white tongue fur, fine and deep pulse.
Continue use the same prescription. The prescription is Shoudi (Cooked rehmannia),
Guiban (tortoise plastron), Duzhong (eucommia), etc. One dosage a day and drink
by twice, 5 days.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
30th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain of any special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. His sleep and appetite are good. His bowel movement and urination are
normal. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient says that the symptoms such as weakness and trembling on his lower
limb obviously are become much less. He can walk about 10 meters along with the
wall¡¯s help, but he still can not control his urine during the night time. Dull
red tongue, thin and white tongue fur, fine and deep pulse. Continue use the
same prescription. The prescription is Shoudi (Cooked rehmannia), Guiban
(tortoise plastron), Duzhong (eucommia), etc. One dosage a day and drink by
twice, 5 days.
Dr. Yang
Qingzhi/ Dr. Dai Lei
Date:
31st of January 2007
Time: 9:00 a.m.
Today the
patient¡¯s general condition is good. Physical examination: heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The check result is the same as before on his lower limb. The patient will leave
our hospital tomorrow.
Dr. Yang
Qingzhi/ Dr. Dai Lei
¡¡
