Brief Summary:
Jonathan, from England, has suffered from
dryness and itching of the skin all over the body for 6 years,
and his condition has been aggravated by the alternative chills
and fever for 3 months. The patient has achieved much
improvement after one-month TCM treatment here.
Record of
Hospitalization
Name:
Jonathan
Sex: Male
Age:
36
Profession: None
Nationality:
London Marital
Status: Married
Onset Season:
Spring Date of
Admission: May 14, 2007
Complainer:
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, and his condition has been
aggravated by alternative chills and fever for 3 months.
Present Illness:
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 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 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 18:30 p.m. on
May 14,
2007. Since
he got the disease, his spirit, his 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 diseases.
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
even-tempered and open-minded.
Marital History:
He
married at
the age of 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
92 beats/minute, R 24 times/minute, BP 150/90 mmHg.
He grew normally
with common nourishment. His mind was clear. He had an
expression of chronic illness and languidness. His body was in a
positive posture and he was cooperative in examination. He had
the symptoms of 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 was 92 times/minute. Cardiac rhythm was
regular. No pathological murmurs of heart on
auscultation. Abdomen
was flat and soft without
tenderness or rebounding tenderness. The liver and spleen were
not palpable. No percussion pains 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.
Other
physiological reflex has not been elicited. His tongue was red
with yellow tongue coating, and slippery pulse.
Diagnostic
examination: Not provided.
First Diagnosis:
TCM diagnosis: Dryness syndrome
Symptom
identification:
Damp toxin and accumulated depression, transformation into
dryness and damage to yin.
Western medicine
diagnosis:
Dryness syndrome
First Medical
Record
6:30 p.m. May 14,
2007
Jonathan, a
36-year-old male, has suffered from dryness and itching of the
skin all over the body for six years, and his condition has been
aggravated by alternative chills and fever for 3 months. He was
picked up by our workers in Zhijiang Airport and arrived in
Huaihua Red Cross Hospital for further treatment at 6: 30 p.m.
on May 14, 2007.
Essentials for
Diagnosis:
1. The patient has
suffered from dryness and itching of the skin all over the body
for six years, and his condition has been aggravated 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 18:30 p.m. on
May 14,
2007. When
the disease attacked the patient, his spirit, his appetite, and
his sleep were all very poor.
His bowel movement and urination were normal.
3. T 36.3¡æ£¬P
92 beats/minute, R 24 times/minute, BP 150/90 mmHg.
4. He grew normally
with common nourishment. His mind was clear.
He had an expression
of chronic illness and languidness.
His body was in a
positive posture and he was 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, and his condition
has been aggravated by alternative chills and fever for 3
months. Dryness syndrome belongs to a kind of the ¡°dryness
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 bowel movement
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, and his condition has been aggravated 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. 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.
Western Medicine:
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 corresponding examination to identify.
First Diagnosis:
TCM diagnosis:
Dryness syndrome
Symptom
identification:
noxious dampness and
heat in melancholy, dryness transformation and impairment of
yin.
Western medicine
diagnosis:
Dryness syndrome
Plans for treatment
strategy and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade II care.
3. Regular diet.
4. Herbal tea: one
dosage a day and drink twice.
Prescription:
Varied Decoction of the Poria Lonicera.
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 15,
2007 Time: 9:00 a.m.
The patient
complained to Dr. Yang about suffering from
dryness, itching and
desquamation of the skin,
as well as
alternative chills and fever.
Examination: T 36.3¡æ£¬P
92 beats/minute, R 24 times/minute, BP 150/90 mmHg. His
heart and lungs 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, and the condition has been aggravated by
alternative chills and fever for 3 months.
2. The patient¡¯s skin was acute dry and itching.
It could be seen some tresis vulnus by scratching and with
serious dephosphorization of the skin. The 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
bowel movement 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 is to take five dosages of the herbal tea
of the same prescription. Wetting Burn Paste for external use,
twice a day. Acupuncture and massage for once a day. The patient
will have more medical examinations if necessary
Date: May 16,
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 kidneys and BS were all
normal. His heart and lungs were normal, and his abdomen was
soft and flat. He presented with a good spirit. His sleep was
good. His bowel movement and urination were normal. His tongue
was red with yellow tongue coating. Doctor¡¯s requirement is to
take herbal tea of the same prescription.
Date: May 17,
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-ultrasonic to the liver, gallbladder, spleen
and pancreata was all normal. When examining the left
kidneys, there is no echo returns. The patients reported that
when he was born, his left-kidney had been examined normally.
But then it became atrophy gradually
to be none so far. He hasn¡¯t received any treatment for it by
now. His
heart and lungs were normal, and his abdomen was soft and flat.
He presented with a good spirit. His sleep was good. His bowel
movement and urination were normal. His tongue was red with
yellow tongue coating. His pulse was slippery. Doctor¡¯s
requirement is to take herbal tea of the same prescription.
Date: May 26,
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
92 beats/minute, R 24 times/minute, BP 150/90 mmHg.
His heart and lungs was normal. His abdomen was soft and flat.
He presented with a good spirit. His 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 is to take herbal tea of the same prescription. One
dosage a day and drink twice. Wetting Burn Paste for external
use, twice a day, accompanied by acupuncture and massage for
once a day.
Date: May 27,
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
92 beats/minute, R 24 times/minute, BP 150/90 mmHg.
His heart and lungs was normal. His abdomen was soft and flat.
He presented with a good spirit. His 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 is to take five dosages of the herbal tea of the
same prescription.
Date: May 30,
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
92 beats/minute, R 24 times/minute, BP 150/90 mmHg.
His heart and lungs was normal. His abdomen was soft and flat.
He presented with a good spirit. His 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
is to take five dosages of the herbal tea of the same
prescription.
Date: June 4,
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 was totally cured.
Examination: T 36.3¡æ£¬P
92 beats/minute, R 24 times/minute, BP 150/90 mmHg.
His heart and lungs was normal. His abdomen was soft and flat.
He presented with a pleasant spirit. His sleep was good. His
bowel movement and urination were normal. Doctor¡¯s requirement
is to take herbal tea of the same prescription. One dosage a day
and drink twice.
Date: June 8,
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
92 beats/minute, R 24 times/minute, BP 150/90 mmHg.
His heart and lungs was normal. His abdomen was soft and flat.
He presented with a good spirit. His 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 is to take three dosages of the herbal tea of the
same prescription.
Date: June 11,
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
92 beats/minute, R 24 times/minute, BP 150/90 mmHg.
His heart and lungs was normal. His
abdomen was soft and flat. He presented with a good
spirit. His 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
the hospital this afternoon. (Date: 11th of June
2007).
