Records of Hospitalization
Name:
Jonathan Sex: Male
Age:
36 Profession: None
Nationality:
London Marital status: Married
Onset Season:
Spring Date of Admission: May 14th,
2007
Complainer of
history: The patient himself Reliability: Reliable
Chief complaint:
The patient has suffered from dryness and itching of the skin all over the body
for six years, aggregately accompanied by alternative chills and fever for 3
months.
Present illness:
Since the
patient was born, he was diagnosed with ¡°dryness syndrome¡± in a hospital, but
then without showing any symptoms. Therefore, the patient did not do any
treatment. Until 2001, the patient suffered from
dryness,
itching and desquamation of the skin all over the body, and then he was treated
in a local hospital (unknown). The Hospital diagnosed it as ¡°dryness syndrome¡±
and gave him treatment with hormones medicine. His disease conditions got some
improvement. After that, his disease attacked repeatedly. He accepted the herbal
treatment in a local hospital, taking herbal tea (unknown) orally. Then he kept
a stable condition. In 2004, he started to take our herbal tea prescribed from
our hospital until now. Over the past 3 months, the patient felt
increasingly dryness and itching of the skin for six years, accompanied by
alternative chills and fever for 3 months.
To get a further systematic treatment, he came to the department of traditional
Chinese medicine of our hospital at 18:30pm on
May 14th
2007. Since he
got the disease, his spirit, appetite, and his sleep were all very poor.
His bowel movement and urination were normal.
Disease history: No
history of typhoid, tuberculosis, hepatitis, malaria
or other infectious disease.
No history of injuries or surgery. No history of medicine or food allergy. No
history of preventive vaccination provided. With the history of dust allergy.
Personal history: He
was born in London, England, living in a cold and damp environment. No contact
history of schistosomiasis. No addiction to alcohol, smoking or special food. He
was mild-tempered and open-minded.
Marital history: He
married at 25 and had a son. His wife and his son are both healthy.
Family history: His
parents are both healthy. No family history of special disease.
Physical examination
T 36.3¡æ£¬P
92bpm, R 24bpm, BP: 150/90mmHg
He was mid-nourished
and normally developed. His mind was clear. He had an expression of chronic
illness and languidness. He was in a positive position and cooperative in
examination. He was with dryness, cracking and
desquamation
of the skin all over the body. No jaundice in the sclera. No superficial
lymph-node enlargement. Bilateral pupils were round, equal in size, and
sensitive to light. No thoracic deformity. Sound of breath was bilaterally
normal on auscultation. No respiratory rales or pleural friction rubs. Heart
border was normal. Heart beat 92bpm. Cardiac rhythm was regular. No pathological
murmurs of heart on auscultation. Abdomen
was flat and soft without tenderness
or rebound tenderness. Liver and spleen were not palpable. No percussion pain on
renal region. Bowel sound was
normal. No Spinal and pelvic deformity or tenderness. His limbs were obviously
seen cracking,
dryness and
desquamation of his skin.
His
physiological reflex has not been elicited. He was with red tongue, yellow and
dry tongue coating. The pulse is stringy-like and slippery.
Diagnostic
examination: Not provided.
First diagnosis:
TCM diagnosis: Zao-syndrome(dryness
syndrome)
Symptom diagnosis:
Damp toxin and accumulated depression, transformation into dryness and damage to
yin.
WM diagnosis:
Dryness syndrome
First Medical Record
6:30p.m. May 14th 2007
Jonathan, a
36-year-old male, has suffered from dryness and itching of the skin all over the
body for six years, aggregately accompanied by alternative chills and fever for
3 months. He was picked up by our staff at Zhijiang Airport and arrived in
Huaihua Red Cross Hospital for further treatment at 6: 30p.m on May 14th
2007.
Essentials for
diagnosis:
1. The patient has
suffered from dryness and itching of the skin all over the body for six years,
aggregately accompanied by alternative chills and fever for 3 months.
2.
Since the patient was
born, he was diagnosed as "dryness syndrome" in a hospital, but then without
showing any symptoms. Therefore, the patient did not do any treatment. Until
2001, the patient suffered from
dryness,
itching and desquamation of the skin, and then he was treated in a local
hospital (unknown). The Hospital diagnosed it as ¡°dryness syndrome¡± and gave him
treatment with hormones medicine. His disease conditions got some improvement.
After that, his disease attacked repeatedly. He accepted the herbal treatment in
a local hospital, taking herbal tea (unknown) orally. Then he kept a stable
condition. In 2004, he started to take our herbal tea by shipping from our
hospital until now. Over the past 3 months, the patient felt
increasingly dryness and itching of the skin for six years, accompanied by
alternative chills and fever for 3 months.
To get a further systematic treatment, he came to the department of traditional
Chinese medicine of our hospital at 18:30pm on
May 14th,
2007. When the
disease attacks, his spirit, appetite, and his sleep were all very poor.
His bowel movement and urination were normal.
3. T 36.3¡æ£¬P
92bpm, R 24bpm, BP: 150/90mmHg
4. He was
mid-nourished and normally developed. His mind was clear.
He had an expression of chronic illness
and languidness.
He was 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.
6. Diagnostic
examination: Not provided
Diagnostic basis
TCM: The patient has
suffered from dryness and itching of the skin all over for six years,
aggregately accompanied by alternative chills and fever for 3 months. Dryness
syndrome belongs to a kind of the ¡°Zao syndrome¡± in traditional Chinese
medicine. It is always caused by internal heat and deficiency of the body
fluids, or deficiency of the blood owing to long illness, or excessive bleeding,
or diaphoresis, vomit and having watery stools leading to the impairment of body
fluids. His red tongue and yellow tongue fur is the reflection of the internal
heat, deficiency of the body fluid and the blood, and dryness transformation.
Western medicine: The
patient has suffered from dryness and itching of the skin for six years,
aggregately accompanied by alternative chills and fever for 3 months.
Since the patient was
born, he was diagnosed as ¡°dryness syndrome ".
Diagnostic
differentiation:
TCM: Dryness
syndrome should be differentiated from the
cool-dryness
syndrome. Cool-dryness syndrome is also named hypo-coldness (Ci han). When it
attacks, the patient feels aversion to cold, fever heat, headache and
adiaphoresis. It often attacks in late Autumn. It has obvious seasonal
difference.
WM:
When it is suspected
to be rheumatism and is done the tests of autoantibodies, it should be
differentiated from some relatively familiar rheumatism such as SIE and RA etc
whether it is 1ss or 2ss, when it arises multiple autoantibodies. Please pay
attention to the dryness of the mouth and eyes with the disease, and do the
responding examination to identify.
First diagnosis
TCM diagnosis: Zao-syndrome(dryness
syndrome)
Symptom diagnosis:
noxious
dampness and heat in melancholy, dryness transformation and impairment of yin.
WM diagnosis:
Dryness syndrome
Plan for treatment
strategy and nursing:
1. On routine care of
traditional Chinese internal medicine
2. On grade II care
3. Regular diet
4. Herbal tea: one
dosage a day and drink twice.
Prescription:
Variable in Poria Lonicera Decoction
Main herbs used in
the herbal tea: Danggui (Tangkuei), Huangqi (Astragalus root), Shengdi (Fresh
rehmannia root), etc.
5. Acupuncture and
massage: once a day
6. Wetting burn paste
for external use, twice a day
7. Have more medical
examinations if necessary.
Date: May 15th
2007 Time: 9:00 a.m.
The patient
complained to Dr. Yang about suffering from
dryness, itching and
desquamation of the skin
aggregately accompanied by alternative chills and fever.
Examination: T 36.3¡æ£¬P
92bpm, R 24bpm, BP: 150/90mmHg.
His heart and lung
was normal. His abdomen was soft and flat.
Dr. Yang¡¯s analysis:
1. The patient has
suffered from dryness and itching of the skin all over the body for six years,
aggregately accompanied by alternative chills and fever for 3 months.
2. The patient¡¯s skin is
acute dry and itching. It can be seen some tresis vulnus by scratching and with
serious dephosphorization of the skin. Limbs dehydrate and slack.
3. The patient was
diagnosed as dryness syndrome in the local hospital. According to the above
information, TCM considers diagnosing as dryness syndrome
(Disorder due to dryness).
It is always caused by internal heat and deficiency of the body fluids,
or deficiency of the blood owing to long illness, or excessive bleeding, or
diaphoresis, vomit and having watery stools leading to the impairment of body
fluids. Dr.
Yang¡¯s analyzes it is
noxious dampness and
heat in melancholy, dryness transformation and impairment of yin. The treatment
strategy is to dispel dampness and to resolve toxin, to nourish yin and to
moisten dryness.
4. Principle of TCM
treatment:
expelling the dampness and resolving toxin, Nourishing yin and moistening
dryness.
Herbal tea prescribed for three days included Tangkuei, Astragalus, fresh
rehmannia root, etc. A daily dosage should be decocted twice. Doctor¡¯s
requirement: take five dosages of herbal tea of the same prescription. Wetting
burn cream for external use, twice a day. Acupuncture and massage for once a
day. The patient will have more medical examinations if necessary
Date: May 16th
2007 Time: 11:30 a.m.
The patient did not
complain about any other special discomfort and told the doctor he had obvious
improvement of dryness and itching of his skin, and the symptom of alternative
chills and fever almost disappeared. His blood was normal. Both of his ESR and
ASO were normal. The function of his liver and kidney and BS were all-normal.
His heart and lung were normal, and his abdomen was soft and flat. He presented
with a good spirit. Her sleep was good. His bowel movement and urination were
normal. His tongue was red with yellow tongue coating. Doctor¡¯s requirement:
take herbal tea of the same prescription.
Date: May 17th
2007 Time: 10:30 a.m.
The patient did not
complain about any other special discomfort and told the doctor he had obvious
improvement of dryness and itching of his skin, and the symptom of
desquamation of his
skin was obvious lessoned. The tresis vulnus of skin dryness is almost cured,
and the
symptom of alternative chills and fever disappeared. The examination of
ECG was normal. The
examination of x-ray chest film was also normal. The examination of B-ultrasomotonography
to liver, gallbladder, spleen and pancreata was all normal. When examining the
left kidney, there is no echo returns. The patients reported that when he was
born. He was examined as normally small left-kidney, and then it became atrophy
gradually to be none so far. Not provide any treatment for it now.
His heart and lung
were normal, and his abdomen was soft and flat. He presented with a good spirit.
Her sleep was good. His bowel movement and urination were normal. His tongue was
red with yellow tongue coating. His pulse was slide. Doctor¡¯s requirement: take
herbal tea of the same prescription.
Date: May 26th
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and he told the doctor he had
obvious improvement of dryness and itching of his skin, and the symptom of
desquamation
of his skin was obvious lessoned. The tresis vulnus of skin dryness is totally
cured, and the
symptom of alternative chills and fever disappeared.
Examination: T 36.3¡æ£¬P
92bpm, R 24bpm, BP: 150/90mmHg.
His heart and lung
was normal. His abdomen was soft and flat.
He presented with a good spirit. Her sleep was good. His bowel movement and
urination were normal.
The treatment
strategy is also to dispel dampness and to resolve toxin, to nourish yin and to
moisten dryness.
Doctor¡¯s requirement:
take herbal tea of the same prescription. One dosage a day and drink twice.
Wetting burn cream for external use, twice a day, and acupuncture and massage
for once a day.
Date: May 27th
2007 Time: 9:00 a.m.
Today the patient did
not complain about any other special discomfort and told the doctor he had
obvious improvement of dryness and itching of his skin, and the symptom of
desquamation
of his skin was obvious lessoned. The tresis vulnus of skin dryness is totally
cured, and
the symptom of alternative chills and fever
disappeared. Examination: T 36.3¡æ£¬P
94bpm, R 24bpm, BP: 150/90mmHg.
His heart and lung
was normal. His abdomen was soft and flat.
He presented with a good spirit. Her sleep was good. His bowel movement and
urination were normal. His tongue was red with thin and white tongue coating.
His pulse was slippery. Doctor¡¯s requirement: to take five dosages of herbal tea
of the same prescription.
Date: May 30th
2007 Time: 9:00 a.m.
Today the patient did
not complain about any other special discomfort and told the doctor he had
obvious improvement of dryness and itching of his skin, and the symptom of
desquamation
of his skin was obvious lessoned. The tresis vulnus of skin dryness is totally
cured, and
the symptom of alternative chills and fever
disappeared. Examination: T 36.3¡æ£¬P
94bpm, R 24bpm, BP: 150/90mmHg.
His heart and lung
was normal. His abdomen was soft and flat.
He presented with a good spirit. Her sleep was good. His bowel movement and
urination were normal. His tongue was red with thin and white tongue coating.
His pulse was slippery. The treatment and the herbal tea are the same as before.
Doctor¡¯s requirement: take five dosages of herbal tea of the same prescription.
Date: June 4th
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and he told the doctor he had
obvious improvement of dryness and itching of his skin, and the symptom of
desquamation
of his skin was obvious lessoned. The tresis vulnus of skin dryness is totally
cured.
Examination: T 36.3¡æ£¬P
92bpm, R 24bpm, BP: 150/90mmHg.
His heart and lung
was normal. His abdomen was soft and flat.
He presented with a good spirit. Her sleep was good. His bowel movement and
urination were normal. Doctor¡¯s requirement: take herbal tea of the same
prescription. One dosage a day and drink by twice.
Date: June 8th
2007 Time: 9:00 a.m.
Today the patient did
not complain about any other special discomfort and told the doctor he had
obvious improvement of dryness and itching of his skin, and the symptom of
desquamation
of his skin was obvious lessoned. The tresis vulnus of skin dryness is totally
cured.
Examination: T 36.3¡æ£¬P
90bpm, R 24bpm, BP: 150/90mmHg.
His heart and lung
was normal. His abdomen was soft and flat.
He presented with a good spirit. Her sleep was good. His bowel movement and
urination were normal. His tongue was red with thin and white tongue coating.
His pulse was slippery. Doctor¡¯s requirement: take three dosages of herbal tea
of the same prescription.
Date: June 11th
2007 Time: 9:00 a.m.
Today the patient did
not complain about any other special discomfort and told the doctor he had
obvious improvement of dryness and itching of his skin, and the symptom of
desquamation
of his skin was obvious lessoned. The tresis vulnus of skin dryness is totally
cured.
Examination: T 36.3¡æ£¬P
90bpm, R 24bpm, BP: 150/90mmHg.
His heart and lung
was normal. His abdomen was soft and flat.
He presented with a good spirit. Her sleep was good. His bowel movement and
urination were normal. His tongue was red with thin and white tongue coating.
His pulse was slippery. The patient was going to leave hospital this afternoon.
(Date: 11th of June 2007).
