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Brief Summary: On Feb. 11, 2009, Tran Bao from Canada, who has suffered from red rashes, accompanied with the symptom of repeated severe itching all over the body for one year, was hospitalized in our hospital. She has achieved significant improvement after 45 days TCM treatment here.

 

Record of Hospitalization

Name: Tran Bao                                                                                                 Birthplace: Canada

Sex: Female                                                                                                        Age: 5

Nationality: Canada                                                                                           Marital Status: Unmarried

Date of Admission: Feb. 11, 2009                                                                    Date of Record: Feb. 11, 2009

Reliability: Reliable                                                                                            Complainer: The patient¡¯s father

 

First Medical Record

Date: Feb. 11, 2009                                      Time: 15: 00 p. m.

Tran Bao, a 5-year-old female, has suffered from red rashes, accompanied with the symptom of repeated severe itching all over the body for one year. She was hospitalized in our hospital for treatment at 24: 00 p. m. on Feb. 11, 2009.

Essentials for Diagnosis:

1. T 36.2¡æ, R 20 times/minute, P 96 times/minute.

2. At present, there were severely itching rashes if the patient took the food that made her discomfort. When she scratched the rashes, they were swelling to form masses or patches with repeated outbreak. Meanwhile, there were no any marks after the disappearance of the wheal. Her stool was dry and smelly. Her body constitution was weak and she was easy to have a cold. Her appetite was not good. She was easy to vomit if there was any discomfort after taking the food. She had no symptoms of spontaneous sweating, night sweating, tidal fever of the soles, palms and center of the chest. The quality of her sleep was not good if she felt the itching of the skin. She was easy to feel tired. Her urine was good.

3. She was cooperative with clear mind. She was skinny. Her tongue was tender-red. Her tongue coating was scant. Her pulse was thready and slippery. Her skin was comparatively dry and the skin of the back of her hands seemed to be rough. She grew normally. The function of the heart and lungs was normal. Heart beat was 96 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation. There were no tapping pains in the area of the kidneys. Her abdomen was soft. There were no pressing pains and rebound tenderness. Physiologic reflex of the nervous system existed, with no pathologic reflex.

Diagnostic Basis:

TCM: Wind is the chief of the hundred diseases and it is swift and changeable, so wind evil invades the body which results in the wheals of the skin. The wheals seem to come and go with repeated outbreak. Blood vacuity engendering the wheals causes yin vacuity and blood dryness, dual vacuity of qi and yin.

Western Medicine: The patient has obvious allergen and skin lesions of the wheals. According to the history of the disease and observation of her body, she is diagnosed with urticaria.

Diagnostic Differentiation:

TCM: The patient¡¯s rubella should be differentiated from chickenpox. Rubella is mainly characterized by itching wheals on the skin. The wheals come and go with repeated outbreak. Meanwhile, there are no any marks after the disappearance of the wheals. However, usually chickenpox occurs in children and the onset of seasons is Spring and Summer. The onset of the part includes the four limbs, waist, abdomen and buttocks. The typical skin lesion is spindle-shaped red papule accompanied with the symptom of severe itching. So they are not difficult to be distinguished.

Western Medicine: The patient¡¯s urticaria should be differentiated from child lichen, which mostly occurs in children. The rashes are papuloid wheal or there are vesicles on the wheals. The rashes will disappear after several days. Regarding urticaria, the rashes on the lesion of the skin come and go. So they are not difficult to be distinguished.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Wind Rash

Symptom identification: Yin vacuity and blood dryness, dual vacuity of qi and yin.

Western Medicine: Urticaria

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Under the care of a companion.

4. Delicate food and avoiding the allergen.

5. Infantile tuina: once a day.

6. TCM treatment strategy: enrich yin, fortify the spleen, boost qi, course wind, dissipate heat, clear heat and cool the blood.

7. Herbal tea: one dosage a day and drink twice.

Main herbs used in the herbal tea: bailian (ampelopsis root), danpi (moutan root bark), gancao(licorice root), etc. 3 dosages in total.

 

Date: Feb. 13, 2009                                      Time: 11: 00 a. m.

Her general condition was good because her father was strict with her food. She just had rice and vegetables. There was no allergic symptom of her skin. Compared with yesterday, the itching and dryness of the skin was slightly improved. Her father said she slept very well last night and there was no skin itching during her sleep. The examination of the urine was normal. Continue to take the same prescription. 4 dosages in total.

 

Date: Feb. 17, 2009                                      Time: 11: 00 a. m.

There was no abnormity of her sleep. The skin of her body became more moistening. There were no red rashes and the itching of the skin. She began to take some food that she couldn¡¯t eat before, such as apple, pear, pork and chicken. Moreover, there was no the symptom of urticaria. Her father was satisfied with the result. Continue to take the same prescription. 5 dosages in total.

 

Date: Feb. 22, 2009                                      Time: 11: 00 a. m.

Her father said she could eat more new kinds of food than before, and there was only slight roseola on the back of her hands and lips. Her sleep and spirit were good. Her stool was slightly dry in the recent two days. Now the skin of her body was slippery and moistening. Her tongue was slightly ruddy. The prescription was as follows: gancao (licorice root), maidong (ophiopogon tuber), maiya (barley sprout), etc. 5 dosages in total.

 

Date: Feb. 25, 2009                                      Time: 11: 00 a. m.

The kinds of the food she could eat were increasing, and there was no allergy, but she could feel the itching of her hands and upper lip due to dryness. Her sleep was generally good. Her father said her weight increased 1kg. The prescription was as follows: baishao (white peony root), danggui (tangkuei), xuanshen (scrophularia root), etc. 3 dosages in total. The herbal tea was also used to wash her hands and lips externally.

 

Date: Feb. 27, 2009                                      Time: 11: 00 a. m.

The itching of the hands was improved due to the external use of the herbal tea. Besides, the skin became more moistening. Her sleep and diet were comparatively good. Continue to take the same prescription for external use for 5 days. Regarding oral herbal tea, the prescription was made a little change.

 

Date: Mar. 4, 2009                                       Time: 11: 00 a. m.

Her condition was comparatively good. She didn¡¯t feel the dryness and itching of the skin. Besides, she could eat various kinds of food, and there was no allergy. Her sleep was good and there was no scratching. Her tongue was still slightly red. Her tongue coating was thin and yellow. Her weight increased 2 kg. The prescription was changed as follows: shaoyao (dioscorea root), shanzha (crataegus fruit), taoren (peach kernel), etc. 5 dosages in total.

 

Date: Mar. 9, 2009                                       Time: 11: 00 a. m.

Her condition was basically good. She could eat various kinds of food. Yesterday she went to the open country. There was slight redness of her lips for an hour, but it disappeared quickly. The redness of her tongue lessened. The prescription was changed as follows: dangshen (codonopsis root), fuling (Poria), bohe (mint), etc. 5 dosages in total.

 

Date: Mar. 14, 2009                                      Time: 11: 00 a. m.

Her diet and sleep were good. There was no obvious allergy in the recent days. The former prescription was changed a little. 5 dosages in total.

 

Date: Mar. 18, 2009                                      Time: 11: 00 a. m.

Her condition was good, and there was no allergy. Her diet and sleep were normal. Her father was ready to take her to Vietnam for 2 weeks with taking 2 weeks herbal tea for continuous treatment. Then they would come back to our hospital. The prescription was the same as before.

 

Date: Apr. 7, 2009                                       Time: 20: 00 p. m.

They came back to our hospital at 19: 00 p. m. on Apr. 7. Her condition was good, and her weight was 19 kg. The prescription was as follows: baishao (white peony root), taizishen (pseudostellaria root), chuanxiong (ligusticum root), etc. 3 doages in total.

 

Date: Apr. 10, 2009                                      Time: 17: 00 p. m.

Professor Yang said it was not the proper time to nourish and supplement the blood because there were rashes on her skin in the recent two days. The treatment strategy was still to clear heat, cool the blood, dispel wind and relieve itching. The prescription was changed as follows: difuzi (kochia fruit), bohe (mint), shechuangzi (cnidium seed), etc. 4 dosages in total.

 

Date: Apr. 13, 2009                                      Time: 16: 00 p. m.

There were no red rashes on her skin, and the skin was moistening. Her sleep and diet were good. Her father decided to take her leave the hospital tomorrow with carrying 2 months herbal tea to consolidate the effect. According to her condition of the whole treatment, the result was good.

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