Records of
Hospitalization
Name:
Abbas Sex:
Male
Age:
62
Profession: Doctor
Nationality: Sudan
Marital status: Married
Onset
Season: Spring
Date of Admission: May 25th, 2007
Complainer of history: The patient himself Reliability: Reliable
Chief
complaint: The patient has suffered from inhibited urination for six years,
accompanied by numbness of the lower limbs.
Present illness:
Six years ago, the patient appeared inhibited urination with strangury, and felt
abdominal distention with some discomfort. Then he went to a local hospital
(unknown) for treatment. After the examination of B-ultrasomotonography, he was
diagnosed with ¡°hypertrophy of the prostate¡±,
and prescribed with
corresponding medicine (unknown). His disease conditions got some
improvement, but his disease attacked repeatedly. The patient still appeared
numbness and pains of the lower limbs, sometimes involving in his toes. The
hospital diagnosed it as ¡°sciatica sciatic neuralgia¡±, and treated with
physiotherapy. Then he got some improvement, but attacked sometimes. On May 13th
2007, he accompanied his wife for her MS treatment in our hospital.
Since he wanted to try traditional Chinese medicine treatment, he started the
treatment on May 25th 2007, together with his wife. Since he got the
disease, his spirit and appetite were both normal, and his sleep was good. His
bowel movement was normal. He was with
inhibited urination.
Disease history: With healthy
body over the past. 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 blood transfusion. No history of
preventive vaccination provided.
Personal
history: He was born in Sudan. 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 23. He has two sons. His wife and his sons are all
healthy.
Family
history: No family history of special inherited disease.
Physical
examination
T 36.5¡æ£¬P
78bpm, R 20bpm, BP: 140/80mmHg
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. Her
skin was moist. 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 80bpm. 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.
No deformity or
inflexibility of the upper limbs.
The patient felt numbness and pains of
the lower limbs, sometimes involving in his toes.
His left and right legs can raise 30 degrees (+). He felt inhibited urination
with strangury.
His physiological reflex has not
been elicited. He was with red tongue, thin and white tongue coating. The pulse
was deep and fine.
Diagnostic examination: Not provided.
First
diagnosis:
TCM
diagnosis: Lin-syndrome (Taxation Strangury)
Symptom
diagnosis: Deficiency of the spleen and kidney, accompanied with damp-heat
brewing.
WM
diagnosis: 1. Hypertrophy of
the prostate
2. L4-S1 lumbar disc protrusion
First
Medical Record
14:30p.m. May 25th 2007
Abbas, a
62-year-old male, has suffered from inhibited urination for six years,
accompanied by numbness of the lower limbs. He arrived in Huaihua Red Cross
Hospital for further treatment at 14:30p.m. on May 25th 2007.
Essentials for diagnosis:
1. The
patient has suffered from inhibited urination for six years, accompanied by
numbness of the lower limbs.
2. Six years ago, the
patient appeared inhibited urination with strangury, and felt abdominal
distention and discomfort. Then he went to a local hospital (unknown) for
treatment. After the examination of B-ultrasomotonography, he was diagnosed as ¡°hypertrophy
of the prostate¡±,
and
prescribed with correspondent
medicine (unknown). His disease conditions got some improvement,
but the disease attacked repeatedly. The patient still appeared numbness and
pains of the lower limbs, sometimes involving in his toes. The hospital
diagnosed it as ¡°sciatica sciatic neuralgia¡±, and treated with physiotherapy.
Then he got some improvement, but attacked sometimes. On May 13th
2007, he accompanied his wife for her MS treatment in our hospital.
Since he also wanted to try traditional Chinese medicine treatment, he started
the treatment on May 25th 2007, together with his wife. Since he got
the disease, his spirit and appetite were both normal. His sleep was good. His
bowel movement was normal. He was with
inhibited urination.
3. T 36.3¡æ£¬P
78bpm, R 20bpm, BP: 140/80mmHg, K: 67kg
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. When the patient discharged urine, he
felt inhibited urination with strangury, accompanied by numbness and pains of
the lower limbs, and sometimes involved in his toes.
His left and right legs could raise 30 degrees (+). The
brinell levy was normal.
6. No
thoracic deformity. Chest percussion noted resonance. Sound of breath was
bilaterally clear on auscultation. No pleural friction rubs.
7.
Diagnostic examination: Not provided
Diagnostic basis
TCM:
The patient has suffered from inhibited urination for six years, accompanied by
numbness of the lower limbs. He was with damp-heat brewing in the lower burner
and inhibited qi transformation of bladder. As his disease attacked repeatedly,
his right qi was damaged gradually, even damage to the spleen and kidney.
Therefore, he was with weak wilting lumbus and knees, fatigue spirit and lack of
strength. His symptoms were sometimes serious, and sometimes mild. As deficiency
of kidney with dampness evil and heat evil, he was suffering from inhibited
urination with strangury. With rough pains continually, he was with weak
constitution after long-term illness. His tongue was light with thin tongue
coating. His pulse was fine and weak.
Western
medicine: The patient has suffered from inhibited urination for six years,
accompanied by numbness of the lower limbs. When he discharged urine, he felt
inhibited urination with strangury, accompanied by numbness and pains of the
lower limbs, sometimes involving in his toes.
Diagnostic differentiation:
TCM:
Taxation Strangury should be differentiated from dribbling urinary block.
Dribbling urinary block is characterized as difficulty in discharging urine with
small quality of urine, even appearing dropping or no urine symptoms. The
symptoms of small quality of urine and difficulty in discharging urine are
similar to Taxation Strangury. Taxation Strangury is characterized as frequent
urine with pains, smaller quality of urine than normal. When it becomes serious,
his urination will occlude. There will be no urine to discharge.
WM: Taxation Strangury should be
differentiated from chronic pyelonephritis, which is with secret course of
disease. A small number of people are intermittently attacked by symptoms of
pyelonephritis. However, symptoms that are more common are these of lower
urinary tract infection, such as intermittent bacteruria without any symptoms,
and intermittently frequent and urgent urination. It has intermittent low-grade
fever.
First
diagnosis
TCM
diagnosis: Lin-syndrome (Taxation Strangury)
Symptom
diagnosis: Deficiency of the spleen and kidney, accompanied with damp-heat
brewing.
WM
diagnosis: 1. Hypertrophy of
the prostate
2. L4-S1 lumbar disc protrusion
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 (to supplement the kidney and to invigorate the lumbus, to quicken the blood
and to transform stasis, to soothe the channels and to quicken the network
vessels): one dosage a day and drink twice.
Prescription: Variable in Kidney-Supplementing Stasis-Quickening Decoction
Main
herbs used in the herbal tea: Shudi (cooked rehmannia root), Danggui (Tangkuei),
Sangjisheng (Mistletoe), etc.
5.
Acupuncture and massage: once a day
6. Have
more medical examinations if necessary.
Date: May
26th 2007 Time: 9:00 a.m.
The patient complained
to Dr. Yan about inhibited urination with strangury, accompanied by numbness and
pains of the lower limbs. The examination of ECG was normal. The examination of
B-ultrasomotonography showed
hypertrophy of the prostate;
six programs of
hepatitis B were normal;
the functions of her liver and kidney were normal, with normal blood sugar and
blood fat. Rheumatoid factor (+). Both of his ESR and anti-¡°O¡± were normal.
Examination: T 36.3¡æ£¬P
78bpm, R 20bpm, BP: 140/80 mmHg.
His heart
and lung were normal. His abdomen was soft and flat.
Dr.
Yan¡¯s analysis:
1. The
patient has suffered from inhibited urination for six years, accompanied by
numbness of the lower limbs.
2. When the patient discharged urine, he
felt inhibited urination with strangury, accompanied by numbness and pains of
the lower limbs, and sometimes involved in his toes.
His left and right legs could raise 30 degrees (+).
3.
National examination: 1.
Hypertrophy of the prostate
2. Sciatica
sciatic neuralgia
According
to the above information, TCM considered it as Lin-syndrome (Taxation Strangury).
Dr. Yan¡¯s analyzed it was
deficiency of the spleen and kidney, accompanied with damp-heat brewing.
Principle of TCM treatment: supplementing the kidney and invigorating the
lumbus, quickening the blood and transforming stasis, soothing the channels and
quickening the network vessels. Herbal tea prescribed for five days including
Shudi (cooked rehmannia root), Danggui (Tangkuei), Sangjisheng (Mistletoe), etc.
One dosage a day and drink twice.
Doctor¡¯s
requirement: take five dosages of herbal tea of the same prescription.
Acupuncture and massage for once a day. The patient will have more medical
examinations if necessary
Date: May
27th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort but told the doctor that he
was still suffering from inhibited urination with strangury, accompanied by
numbness and pains of the lower limbs. His heart and lung were normal. His
abdomen was soft and flat. His spirit and appetite were both normal, and his
sleep was good. His bowel movement was normal. The examination to his lower
limbs was the same as before. His tongue was slightly red with thin and white
tongue coating. His pulse was deep and fine. Doctor¡¯s requirement: take herbal
tea of the same prescription.
Date: May
28th 2007 Time: 9:00 a.m.
Today the
patient did not complain about any other special discomfort but told the doctor
that his inhibited urination with strangury and numbness and pains of the lower
limbs all got some improvement. His heart and lung were normal, and his abdomen
was soft and flat. His spirit and appetite were both normal, and his sleep was
good. His bowel movement was normal. The examination to his lower limbs was the
same as before. His tongue was slightly red with thin and white tongue coating.
His pulse was deep and fine. Doctor¡¯s requirement: take herbal tea of the same
prescription.
Date: June
2nd 2007 Time: 9:00 a.m.
Today the
patient did not complain about any other special discomfort. Meanwhile he told
the doctor that his inhibited urination with strangury and numbness and pains of
the lower limbs all got some improvement. His heart and lung were normal, and
his abdomen was soft and flat. His spirit and appetite were both normal, and his
sleep was good. His bowel movement was normal. The examination to his lower
limbs was the same as before. His tongue was slightly red with thin and white
tongue coating. His pulse was deep and fine. Doctor¡¯s requirement: take five
dosages of herbal tea of the same prescription. One dosage a day and drink
twice.
Date: June
7th 2007 Time: 9:00 a.m.
Today the
patient did not complain about any other special discomfort. Meanwhile he told
the doctor that his inhibited urination with strangury and numbness and pains of
the lower limbs all achieved obvious improvement. His heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was good. His bowel movement was normal. The examination
to his lower limbs was the same as before. His tongue was slightly red with thin
and white tongue coating. His pulse was deep and fine. Doctor¡¯s requirement:
take herbal tea of the same prescription.
Date: June
12th 2007 Time: 9:00 a.m.
Today the
patient did not complain about any other special discomfort. His disease
condition was stable.
Date: June
14th 2007 Time: 9:00 a.m.
Today the
patient did not complain about any other special discomfort. Meanwhile he told
the doctor that his inhibited urination with strangury almost disappeared. His
numbness and painful lower limbs achieved obvious improvement. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were both normal, and his sleep was good. His bowel movement was normal. His
tongue was slightly red with thin and white tongue coating. His pulse was deep
and fine. The patient would discharge from our hospital today.
