Record of
Hospitalization
Name: Mr. W. Sex:
male
Age: 42 Nationality: Ireland
Marital status: married Date
of admission: Feb 4, 2006
Date of record: Feb 4, 2006 Narrator of
medical history: patient himself
Major complaint:
Increased urinary frequency, strong prostate
pains, painful urination. These have been lasting for 13 years
constantly.
The medical history:
The patient had the symptoms above 13years
ago, especially after a long-time job, but he didn¡¯t pay special
attention. Consequently, the symptom was more serious. He had
experienced the western treatment for 2 months in his local
country, but no special improvement. In the September, 2005, he
went to Xiang Ya Hospital, Chang Sha city, Hu Nan province, to
try Chinese-Western-combined treatments and acupuncture, massage
treatments, but still no improvement. Now, the patient has the
symptom of yellowish urinary, burning pain in the urethra,
perineum-ache, waist-ache and distending pain in his lower
abdomen, cold-pain feeling in the lower abdomen, loss of sexual
function, hypodynamia, without headache and dizziness, unclear
vision, slightly tinnitus in his ears, snuffle, baldness,
constant cold-feeling on his back, dry and bitter mouth and with
the desire for warm water, good appetite, easily-hungry but eat
little, easily wake-up. He sometimes has difficulty in bowel
movement and the feeling of weakness after that.
Other diseases:
He had been suffering from the disease of
lupus for 8 years. After so many kinds of western medicines, he
began to suffer the pain in all his body-joints. He also
suffered from rhinitis and took twice operations for the nasal
cavity.
Personal history:
He was born in Ireland , has been to America
and Chang Sha city, china, for treatment. No habit of smoking
and, no other bad habit, his living condition is quite good. He
got married at 28, and his wife is quite healthy.
History of his family:
The parents of this patient are healthy, no
other special disease.
Physical examination:
His growth and nutrition are good, clear
mind, cooperate with us, expression is normal, no yellowish
stain on his skin sclera, no blood point and tetter, voice is
loud enough, shortness of breath, white and damp tongue coating,
weak pulse, head and five sense organs are normal, no hyperemia
in the throat, no monstrosity in his vertebral column and four
limbs, but there are clear pressing-pains in his vertebral
column and articutio sacralis. No edema in his pubes part,
dampness in this part, but peculiar smell, the doctor can feel
the hardness of his prostate.
Diagnostic Gist:
According to the theories of TCM and the
symptoms above, we can diagnose the disease as stranguria, which
is because of deficiency of the kidney.
Differential Diagnosis:
The main symptom is the frequency of
urination, prostate pains and pain in urination, which have been
out breaking constantly for 13 years. This disease is in the
category of stranguria, which is different from ¡°dribbling
block¡±. The symbol of the latter is also urinary abnormity, but
the symptom of the latter does not conclude the frequency of
urination and the pain in stranguria. According to the analysis
above, we can conclude that the disease is chronic protatitis.
Treatment plan:
1. internal medicine tending routine
2. second grade tending
3. low-fat and low-salt diet
4. The herbal tea is for warming and invigorating kidney-yang,
invigorating the circulation of blood and removing dampness
by diuresis.
February 5, 2006.
The symptoms of increased-urinary-frequency,
prostate pains, urodynia are slightly better, soreness of the
waist and knees, general lassitude, blurred vision, general body
pains, especially the pain in his vertebral column and
knee-joints is obvious, slight loss of hair, tinnitus, snuffle,
cold sense on the back, having problem of breathing in the night
(he has been using the respirator for 3 years), weakness after
bowel movement, feel worse after being tired.
Dr. Yang and Dr. Li
Feb 6, 2006.
He says he obviously feels better after
yesterday¡¯s treatment. He urinated 4 times last night, but the
urodynia disappeared, slept well, and energetic, the soreness of
muscles and body-joints reduced, and only slight pains left.
Leonurus 20g, salvia root 30g, peach
kernel 10g, etc.
Dr. Li
Feb 8, 2006.
The patient says he urinated 3 times last
night, no precipitation urination, but the abdomen near the
prostate was still painful, much better than yesterday. The
aching pains of his general body was reduced.
His rectum was painful when defecating and he
felt weak after the bowel movement, his nerve system is normal.
Leonurus 20g,
salvia root 30g, peach kernel 10g, etc.
Dr. Li
Feb 10, 2006.
He says urodynia appeared again, and he
wanted to urinate all the time, the abdomen near the prostate
was obviously painful, but he felt nothing discomfort when
urinating. The aching pains of his general body was reduced
more. The pain around his rectum was slightly reduced. He says
he is recovered by about 20%.
dioscorea root 10g,
cooked
rehmannia root 10g, Poria 10g, etc.
Pediluvium
formula:
Prepared aconite
main tuber 10g, cinnamom twig 30g, tangkuei 20g, etc.
Dr. Li
Feb 12, 2006.
The patient says his prostate was still
painful, but was much better. He slept well for 4¡ª5 hours last
night. The pains of his knee-joints, neck, back and articulatio
sacralis were much reduced. Appetite was good. His mouth was
bitter, but not dry. He says the pains of prostate are reduced
by more than 20%, and that of his general body are reduced by
about 40%.
dioscorea root
10g,
cooked
rehmannia root 10g, Poria 10g, etc.
Dr.
Li
Feb 15, 2006.
He says he only slept 4 hours. He has a
little bit diarrhea, but no obvious discomfort. The dampness and
cold-pains in his prostate before urinary was reduced a little.
The pains in his general body was much reduced. Appetite was
good, mouth wasn¡¯t dry, he says the pain in his prostate are
reduced 40%, and pains of his general body are reduced 40% to
60%.
dioscorea root
10g,
cooked
rehmannia root 10g, Poria 10g, etc.
Dr. Li
Feb 17, 2006.
He says he slept for 6 hours last night. He
only urinated one time after he waked up in the 6:00, the
feeling of coldness and dampness in his
lower abdomen was still obvious. He
felt a little bit weak. Appetite is good.
dioscorea root
10g,
cooked
rehmannia root 10g, Poria 10g, etc.
Dr. Li
Feb 19, 2006.
He says he slept 7 hours
last night. He did not wake up for urination after he fell
asleep. The feeling of coldness and dampness in his lower
abdomen was much reduced by about 70%.
dioscorea root
10g,
cooked
rehmannia root 10g, Poria 10g, etc.
Dr. Li
Feb 21, 2006.
Today the patient is
very well. He didn¡¯t urinate last night. His lower abdomen was a
little bit cold-pain. He feels energetic today.
Feb 22, 2006.
He says his prostate was
worse from yesterday afternoon. He felt his urination was
frequent and urgent. He couldn¡¯t sleep well.
dioscorea root
10g,
cooked
rehmannia root 10g, Poria 10g, etc.
Dr. Li
Feb 23, 2006.
He is much better than
yesterday, the pains are reduced but he can¡¯t sleep well,
because he urinated 4 times last night. He felt distension in
his prostate before urination. There are only slight pains in
his general body.
dioscorea root
10g,
cooked
rehmannia root 10g, Poria 10g, etc.
Dr. Li
Feb 25, 2006.
He says his prostate is
much better than the last 2 days. He could sleep well for 7
hours. But he still feels a little bit painful after urination.
dioscorea root
10g,
cooked
rehmannia root 10g, Poria 10g, etc.
Dr. Li
Feb 27, 2006.
He says there is no
change in his lower abdomen, he could sleep well. He slept 7
hours last night. He says he has been recovered about 60%.
dioscorea root
10g,
cooked
rehmannia root 10g, Poria 10g, etc.
Pediluvium
formula:
cinnamom twig
30g, prepared aconite main tuber 10g, mugwort leaf 30g, etc.
