Records of Hospitalization
Name:
Abdul Salim Sex:
Male
Nationality:
Singaporean Age:
9
Marital status:
Unmarried Date of Admission:
Nov. 13th, 2006
Onset Season:
Summer Date of Report:
Nov. 13th, 2006
Complainer of
history:
The patient¡¯s father
Reliability:
Reliable
Chief complaint:
The patient has suffered from lame walking and inability to
squat for four years accompanied by an aggravated duck-gait for
two years.
Present illness:
At the end of 2002, the patient had a changing in walking
posture without any evident predisposing cause. He began to slow
down his walking speed and standing up after squatting. At that
time, his family neither paid much attention to him, nor took
him to do any examination treatment. In 2004, the patient¡¯s
condition was aggravated. He had difficulties in walking and
with imbalance. He had difficulties in squatting and unable to
get up when supine in bed (He needs to turn over and slowly
picks himself up) and walking with duck-gait posture. His
parents checked at the local hospital, but the chromosome
examination showed no abnormality. The diagnosis for the patient
was ¡°DMD¡± by MRI and blood test, so he orally took drugs named
"Prednisolone" until now and without further treatment so far.
Two months ago, the patient started to take Chinese medicine
posted by our hospital. The patient has good spirit and sleep,
enormous appetite, thin and white tongue fur, slightly reddish
tongue, fine and deep pulse.
Past history:
No history of typhoid, tuberculosis and hepatitis. No history of
food or medicine allergy. No history of operation or
transfusion. No history of preventive
vaccination provided.
Personal history:
He was born in Singapore, living in a humid environment. No
contact history of schistosomiasis. No addiction to alcohol,
smoke or special food. He is calm temperament and cheerful.
Marital history:
Unmarried.
Family history:
No family history of special disease.
Physical
examination
T 36.2¡æ£¬P
90bpm, R 23bpm, BP: 96/70mmHg, W 36kg.
He is mid-nourished and normally developed. His mind is clear,
chronic face mirroring difficult condition, languor expression,
in a positive position and cooperative in examination. His skin
is moist. No jaundice in the sclera. No superficial lymph-node
enlargement. Bilateral pupils are 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 is not big. Heart beat
90bpm. Cardiac rhythm was regular. No pathological murmurs of
heart on auscultation.
Abdomen is flat and
soft without tenderness or rebound tenderness. Liver and spleen
are not palpable. No percussion pain on renal region. Bowel
sound is normal. No
Spinal and pelvic deformity or tenderness. Both upper limbs
without deformity and normal mobility, both lower extremities
will see the special examination. The development of the
anus or genital was normal. Physiological reflex has
pathological features without elicited.
Special examination:
The patient has suffered from lame walking and accompanied by a
duck-gait; can not run, difficulties on stepping up the stairs
and squatting down. When he squats, he has to stand up slowly by
knees down and hands supported by the ground. He has to turn
over when lying face upward, and using his two hands to climb
with bent knees supported then slowly rising upward. Both side
of gastrocnemius are hypertrophic and hard.
Accessory
examination:
MRI shows ¡°DMD¡±.
First diagnosis:
TCM diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom diagnosis:
Spleen and stomach asthenia; liver and kidney asthenia and
phlegm turbidity.
WM diagnosis:
Progressive muscular dystrophy (Pseudo-mast); ¡°DMD¡±.
Dr. Yan Zaoming/ Dr. DaiLei
First
Medical Record
9:00 a.m. November
13th, 2006
Abdul Salim, male, has suffered from lame walking and inability
to squat for four years accompanied by an aggravated duck-gait
for two years. He was picked up by our workers and arrived in
Huaihua Red Cross Hospital at November 13th, 2006.
Case
characteristics:
1. The patient has suffered from lame walking and inability to
squat for four years accompanied by an aggravated duck-gait for
two years.
2. At the end of 2002, the patient had a changing in walking
posture without any evident predisposing cause. He began to slow
down his walking speed and standing up after squatting. At that
time, his family neither paid much attention to him, nor took
him to do any examination treatment. In 2004, the patient¡¯s
condition was aggravated. He had difficulties on walking and
with imbalance. He had difficulties on squatting and unable to
get up when supine in bed (He needs to turn over and slowly
picks himself up) and walking with duck-gait posture. His
parents checked at the local hospital, but the chromosome
examination showed no abnormality. The diagnosis for the patient
was ¡°DMD¡± by MRI and blood test, so he orally took drugs named
"Prednisolone" until now and without further treatment so far.
Two months ago, the patient started to take Chinese medicine
posted by our hospital. The patient has good spirit and sleep,
enormous appetite, thin and white tongue fur, slight reddish
tongue, fine and deep pulse.
3. T 36.2¡æ£¬P
90bpm, R 23bpm, BP: 96/70mmHg, W 36kg.
4. He is mid-nourished and normally developed. His mind is
clear, chronic face, languor expression, in a positive position
and cooperative in examination.
5. The patient has suffered from lame walking and accompanied by
a duck-gait; he can not run, difficulties on stepping up the
stairs and squatting down. When he squats, he has to stand up
slowly by knees down and hands supported by the ground. He has
to turn over when lying face upward, and using his two hands to
climb with bent knees supported to rise upward.
6. No thoracic deformity. Chest percussion noted resonance.
Sound of breath was bilaterally clear on auscultation. No
pleural friction rubs.
7. Accessory examination: Not provided yet.
Diagnostic basis
TCM:
The patient has suffered from lame walking and inability to
squat for four years accompanied by an aggravated duck-gait for
two years. Kidney is congenital basic, stores essence, governs
the bones and engenders marrow. Kidney stores original Yin and
original Yang, if congenital insufficiency, kidney vacuity and
depletion, insufficient essence-blood and bone losses nourish
then desiccation of the bone and vacuity of the marrow. The
symptom shows the feet moving out of controlling of the body,
lumbar spine failed to rise, engendered as bone wilting. On the
political dialectic: Dual vacuity of the spleen and kidney,
spleen and stomach are the root of later heaven and the
resources of engendering transformation Qi-blood fluid. Mainly
governs muscles and limbs. If spleen and stomach are vacuous
then the five viscera have nothing to support, the grain and
water can not reach the limbs and make muscles atrophied. If it
is ahead of the kidney original yang inadequate, debilitation of
the life gate fire, it can not warm spleen yang and
spleen-stomach vacuity cold. The function of intake and
motivation-transformation are abnormal, insufficient of the
resources of Qi-blood fluid engender and transformation, the
muscles can not get moistened, so the muscle of the limbs
wilting, soft and lack of strength, start from muscle wilts,
congenital insufficiency, dual Qi and blood vacuity, and can not
nourish sinew, bone and muscle then cause limbs weakness and
muscular atrophy. Because of congenital insufficiency, loss of
later heaven nourish and Qi-blood vacuity lead to five viscera
internal injury, bowels and viscera Qi-blood dysfunction, and
made Qi-blood much more vacuous and developing the muscular
atrophy, soft and weakness.
Western medicine
basis:
The patient has suffered from lame walking and inability to
squat for four years accompanied by an aggravated duck-gait for
two years, can not run, difficulties on stepping up the stairs
and squatting down. When he squats, he has to stand up slowly by
knees down and hands supported by the ground. He has to turn
over when lying face upward, and using his two hands to climb
with bent knees supported then slowly rising upward. The
diagnosis from the local hospital is ¡°DMD¡±.
Diagnostic
differentiation£ºTCM
differentiated from Bi-syndrome. Late stage of Bi-syndrome, due
to the joint pain in limbs; he can not move because he hasn¡¯t
used his limbs for a long time has similar symptoms as
Wei-syndrome, such as thin and wilt, yet the person who gets
Wei-symptom usually has no joint pain on the limbs. On the
contrary, Bi-syndrome usually characterized by aching pain.
Because of its etiology and pathogenesis are different, so do
their treatments. These should be differentiated.
WM differentiated
from amyotrophic lateral sclerosis:
Most patients get the disease between the ages of 30 to 50. This
kind of disease has a slow onset. Most of the patient start
onset from one side of the body limbs, later on it develops into
both sides. The common onset pattern starts from the upper
limbs, showing inflexible movement and muscular dystrophy,
indicated as "claw hand", and then gradually developing to the
forearm, upper arm and shoulder muscles, with aggravation of the
muscular dystrophy, weakness of the limbs leading to paralysis.
This should be distinguished.
First diagnosis
TCM diagnosis:
Wei-symptom (flaccidity syndrome)
Symptom diagnosis:
Spleen and stomach asthenia; liver and kidney asthenia and
phlegm turbidity.
WM diagnosis:
Progressive muscular dystrophy (Pseudo-mast); ¡°DMD¡±.
Plan of the
treatment:
1. On routine care of traditional Chinese internal medicine
2. On grade II care
3. Nurse
4. Low salt, sugar and fat diet
5. Herbal tea: Boost Qi and fortify the spleen, supplement the
kidney and strengthening the sinew. Such as Guiban (tortoise
plastron), Baishao (Paeonia Lactiflora), lujiaoshuang
(Degelatinated Deerhorn), etc. One dosage a day and drink by
twice.
6. Massage once a day
7. Acupuncture once a day
8. Have more medical examinations if necessary
Dr. Yan Zaoming/ Dr. DaiLei
Date: 14th
of November 2006
Time:
9:00 a.m.
Deputy Chief
Physician rounds
This morning is Deputy Chief
Physician Yan Zaoming¡¯s ward-round. The patient complained that
his lower limb weakness, he can not run, difficulty squatting,
unstable walking accompanied by a duck-gait. Examination: T 36.2¡æ£¬P
90bpm, R 23bpm, BP: 96/70mmHg, W 36kg. The patient suffered from
lame walking and accompanied by a duck-gait; he can not run,
difficulties on stepping up the stairs and squatting down. When
he squats, he has to stand up slowly by knees down and hands
supported by the ground. He has to turn over when lying face
upward, and using his two hands to climb with bent knees
supported to rise upward. Dr. Yan analyzed as the following:
1. The patient has suffered from lame walking and inability to
squat for four years accompanied by an aggravated duck-gait for
two years.
2. Body check as stated above.
3. The diagnosis from the local hospital: Progressive muscular
dystrophy (Pseudo-mast), ¡°DMD¡±. According to the materials from
up stated, TCM considered it as Wei-symptom. Wei-symptom is a
kind of disease with limbs atony, soft-weakness, can not move
freely or accompanied with muscular atrophy.
In clinical terms:
It often seen the lower limb wilting and weakness, and also
named ¡°wilting-bi¡¯.
Suwen-Angry
Discussion
pointed out that, ¡°due to wet, first as warp, large sinew is
soft-shorten, small sinew is loose-lengthen, soft-shorten is
hypertonicity and loose-lengthen is wilt (Wei).¡± Its causes are
very complicated. The external cause is warm-heat evil with
toxicity, affect-mind internal damage, tired during eating and
drinking, insufficient of earlier heaven (be born congenitally
deficient), and excessive sexual activities. Injuries from
falls, touching neurotoxicity drugs and so on can lead to five
viscera damages. Insufficient of essence and liquid, depleted
Qi-blood, sinews, vessels and muscles deprived of nourishment,
can finally lead to Wei-symptom (flaccidity symptom). The
treatment of Wei-syndrome should be focused on the meridian of
yangming because Yangming is the sea of the Zang-Fu organs, and
also governs the moistening. The main sinews and the main sinews
charge the born then invigorate the body. Body liquid,
essence-blood both come from spleen and stomach. If the movement
and transformation of the spleen and stomach is not strong, or
insufficiency of the source of transforming the essence blood,
sinew and vessel deprived of nourishment leads to useless wei-bi
(Wilt-low limbs).
Dialectical:
Spleen and stomach asthenia; liver and kidney asthenia and
phlegm turbidity. Treatment principle: Boost Qi and fortify the
spleen, supplement the kidney and strengthen the sinew, sweep
phlegm and open the orifices. Prescription: Add or reduce
medicine of Two Immortals Decoction of kidney-enrich: Such as
Guiban (tortoise plastron), Baishao (Paeonia Lactiflora),
lujiaoshuang (Degelatinated Deerhorn), etc. One dosage a day and
drink by twice, 3 days. Acupuncture and massage once a day, and
have more medical examinations if necessary.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 15th
of November 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any special discomfort. He
complained that his lower limb weakness, lame walking and
accompanied by a duck-gait; he can not run, difficulties on
stepping up the stairs and squatting down. No aversion to cold.
No fever. No headache or dizziness. No nausea or vomiting. He
presents with a good spirit. His sleep is good. His bowel
movement and urination are normal. Thin and white tongue fur,
slight reddish tongue, fine and deep pulse.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 16th
of November 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any special discomfort. He
complained that his lower limb still weakness, lame walking and
accompanied by a duck-gait, can not run, difficulties on
stepping up the stairs and squatting down. When he squats, he
has to stand up slowly by knees down and hands supported by the
ground. He has to turn over when lying face upward, and using
his two hands to climb with bent knees supported to rise upward.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has
enormous appetite and sleep is good. His bowel movement and
urination are normal. Thin and white tongue fur, slight reddish
tongue, fine and deep pulse. Give the same prescription, 3 more
days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 19th
of November 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any special discomfort. He
complained that his lower limb still weakness, but a little
better, lame walking and accompanied by a duck-gait, can not
run, difficulties on stepping up the stairs and squatting down.
When he squats, he has to stand up slowly by knees down and
hands supported by the ground. He has to turn over when lying
face upward, and using his two hands to climb with bent knees
supported to rise upward. No aversion to cold. No fever. No
headache or dizziness. No nausea or vomiting. He presents with a
good spirit. His sleep was good. His bowel movement and
urination were normal. Thin and white tongue fur, slight reddish
tongue, fine and deep pulse. Give the same prescription, 5 more
days. Such as Shoudi (cooked rehmannia), Suoyang (Cynomorium
songaricum), lujiaoshuang (Degelatinated Deerhorn), etc. One
dosage a day and drink by twice, 5 days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 22nd
of November 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any special discomfort. He
complained that his lower limb weakness is a little better, lame
walking and accompanied by a duck-gait; he can not run,
difficulties on stepping up the stairs and squatting down. When
he squats, he has to stand up slowly by knees down and hands
supported by the ground. He has to turn over when lying face
upward, and using his two hands to climb with bent knees
supported to rise upward. No aversion to cold. No fever. No
headache or dizziness. No nausea or vomiting. He presents with a
good spirit. His sleep was good. His bowel movement and
urination were normal. Thin and white tongue fur, slight reddish
tongue, fine and deep pulse. Continue using the same
prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 25th
of November 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any special discomfort. He
says that his lower limb weakness is much better, but still lame
walking and accompanied by a duck-gait; he can not run,
difficulties on stepping up the stairs and squatting down. When
he squats, he has to stand up slowly by knees down and hands
supported by the ground. He has to turn over when lying face
upward, and using his two hands to climb with knee-joints
supported to rise upward. No aversion to cold. No fever. No
headache or dizziness. No nausea or vomiting. He presents with a
good spirit. He has enormous appetite and sleep good. His bowel
movement and urination are normal. Thin and white tongue fur,
slight reddish tongue, fine and deep pulse. Continue using the
same prescription, 5 more days. Such as Shoudi (cooked
rehmannia), Suoyang (Cynomorium songaricum), Guijiao (tortoise
plastron glue), etc. One dosage a day and drink by twice, 5
days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 28th
of November 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other discomfort. He says
that his lower limb weakness is much better, lame walking is a
little better, but still accompanied by a duck-gait, can not
run, difficulties on stepping up the stairs and squatting down.
When he squats, he has to stand up slowly by knees down and
hands supported by the ground. He has to turn over when lying
face upward, and using his two hands to climb with knee-joints
supported to rise upward. Thin and white tongue fur, slight
reddish tongue, fine and deep pulse. Continue using the same
prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 1st
of December 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other discomfort. He says
that his lower limb weakness is much better, lame walking is a
little better, but still accompanied by a duck-gait, can not
run. He can climb up 10 steps of the stairs by somebody¡¯s help,
difficulties on squatting down. When he squats, he has to stand
up slowly by knees down and hands supported by the ground. He
has to turn over when lying face upward, and using his two hands
to climb with knee-joints supported to rise upward. Thin and
white tongue fur, slight reddish tongue, fine and deep pulse.
Continue using the same prescription, 5 more days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 4th
December 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other discomfort. He says
that his lower limb weakness is much better, lame walking is a
little better, but still accompanied by a duck-gait, can not
run. He can climb up 10 steps of the stairs by somebody¡¯s help,
difficult on squatting down. When he squats, he has to stand up
slowly by knees down and hands supported by the ground. He has
to turn over when lying face upward, and using his two hands to
climb with knee-joints supported to rise upward. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse.
Continue using the same prescription. Such as Guijiao (tortoise
plastron glue), Suoyang (Cynomorium songaricum), lujiaoshuang
(Degelatinated Deerhorn), etc. One dosage a day and drink by
twice.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 7th
of December 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other discomfort. He says
that his lower limb weakness is much better, lame walking is a
little better, but still accompanied by a duck-gait, can not
run. He can climb up 10 steps of the stairs by somebody¡¯s help,
difficulties on squatting down. When he squats, he has to stand
up slowly by knees down and hands supported by the ground. He
has to turn over when lying face upward, and using his two hands
to climb with knee-joints supported to rise upward. Thin and
white tongue fur, slight reddish tongue, fine and deep pulse.
Continue using the same prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 10th
of December 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other discomfort. He says
that his lower limb weakness is much better, lame walking is a
little better, but still accompanied by a duck-gait, can not
run. He can climb up 10 steps of the stairs by somebody¡¯s help,
difficulties on squatting down. When he squats, he has to stand
up slowly by knees down and hands supported by the ground. He
has to turn over when lying face upward, and using his two hands
to climb with knee-joints supported to rise upward. Thin and
white tongue fur, slight reddish tongue, fine and deep pulse.
Continue using the same prescription. Such as Yujin (curcuma
tuber), Dansheng (Salvia), Shengdi (fresh rehmannia), etc.
Dr. Yan zaoming/ Dr. Dai Lei
Stage Summary
Date: 12th
of December 2006
Time: 9:00 a.m.
The patient, Abdul Salim, a 10-year-old male, has suffered from
lame walking and inability to squat for four years accompanied
by an aggravated duck-gait for two years. He has admitted in our
Red Cross Hospital about 30 days since November 11th,
2006.
Admission
situation:
The patient has suffered from lame walking and inability to
squat for four years accompanied by an aggravated duck-gait for
two years. No headache or dizziness. No nausea or vomiting. No
aversion to cold. No fever. He presents with a good spirit. His
appetite and sleep is good. His bowel movement and urination are
normal. Physical examination:
T 36.2¡æ£¬P
90bpm, R 23bpm, BP: 96/70mmHg, W 36kg, heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient has suffered from lame walking and accompanied by a
duck-gait; he can not run, difficulties on stepping up the
stairs and squatting down. When he squats, he has to stand up
slowly by knees down and hands supported by the ground. He has
to turn over when lying face upward, and using his two hands to
climb with bent knees supported then slowly rising upward. Thin
and white tongue fur, slight reddish tongue, fine and deep
pulse. MRI: Progressive muscular dystrophy ¡°DMD¡±.
Admission
diagnosis:
TCM diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom diagnosis:
Spleen and stomach asthenia; liver and kidney asthenia.
WM diagnosis:
Progressive muscular dystrophy; ¡°DMD¡±.
Diagnosis and
treatment process:
After the patient was admitted in our hospital, we gave him
Chinese medicine to boost Qi and fortify the spleen, supplement
the kidney and strengthen the sinew. The prescription is Two
Immortals Decoction of kidney-enrich, adding or reducing the
medicine. One dosage a day and drink by twice. Acupuncture and
massage once a day. His health condition improved due to the
combined treatment.
Present condition:
His lower limb weakness and lame walking are much better, but
still can not run. He can climb up about 10 steps of the stairs
by himself now. Difficulty on squatting down is a little better.
When he squats, he has to stand up slowly by knees down and
hands supported by the ground. He has to turn over when lying
face upward, and using his two hands to climb with knee-joints
supported to rise upward.
Present diagnosis:
TCM diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom diagnosis:
Spleen and stomach asthenia; liver and kidney asthenia.
WM diagnosis: ¡°Progressive
muscular dystrophy¡±, DMD.
Plan of the
treatment:
1. In order to improve more of his disease condition, we
suggested the patient to extend 30 days treatment.
2. Continue the combined treatment of Chinese medicine,
acupuncture, massage and functional training.
Dr. Yan zaoming/ Dr. Dai Lei
Suoyang (Cynomorium songaricum)
One dosage a day and drink by twice, 5 days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 13th
of December 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other discomfort. He says
that his lower limb weakness is much better, lame walking is a
little better, but still accompanied by a duck-gait, can not
run. He can climb up 10 steps of the stairs slowly by himself
now, difficulties on squatting down is a little better. When he
squats, he has to stand up slowly by knees down and hands
supported by the ground. He has to turn over when lying face
upward, and using his two hands to climb with knee-joints
supported to rise upward. Thin and white tongue fur, slight
reddish tongue, fine and deep pulse. Strengthen the functional
training. Continue using the same prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 16th
of December 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other discomfort. He says
that his lower limb weakness is much better, lame walking is a
little better, but still accompanied by a duck-gait, can not
run. He can climb up about 10 steps of the stairs slowly by
himself, difficulties on squatting down is a little better. When
he squats, he has to stand up slowly by knees down and hands
supported by the ground. He has to turn over when lying face
upward, and using his two hands to climb with knee-joints
supported to rise upward. Thin and white tongue fur, slight
reddish tongue, fine and deep pulse. Strengthen the patient¡¯s
functional training. Continue using the same prescription. Such
as Suoyang (cynomorium songaricum), Shoudi (cooked rehmannia),
Yujin (curcuma tuber), etc. One dosage a day and drink by twice,
5 days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 19th
of December 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other discomfort. He says
that his lower limb weakness is much better, lame walking is a
little better, but still accompanied by a duck-gait, can not
run. He can climb up about 10 steps of the stairs slowly by
himself, difficulties on squatting down is a little better. When
he squats, he has to stand up slowly by knees down and hands
supported by the ground. He has to turn over when lying face
upward, and using his two hands to climb with knee-joints
supported to rise upward. Thin and white tongue fur, slight
reddish tongue, fine and deep pulse. Strengthen the functional
training. Continue using the same prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 20th
of December 2006
Time: 9:00 a.m.
Today the patient complains that he has two times diarrhea this
morning. He presented with a bad spirit. His urination is
normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
He has obvious pain on the right side of the abdomen, no rebound
tenderness. Liver and
spleen were not palpable. No percussion pain on renal region.
Bowel sound was
normal. Urgency check: Blood RT result: WBC 4.8¡Á109/L,
C-RA% 70.0%, RBC 4.83¡Á1012/L.
Basically ruled out the diagnosis of acute appendicitis, and
give the patient No. 4 Fupaisuan capsules. Two tablets a time
and two times a day. Observe the patient¡¯s disease condition.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 21st
of December 2006
Time: 9:00 a.m.
Today the patient complains that he
still had diarrhea two times last night. He presented with a bad
spirit, sleep and a little bad appetite. His urination is
normal. No aversion to cold. No fever. No headache or dizziness.
No nausea or vomiting. Physical check: T 36.6¡æ£¬P
78bpm, R 20bpm, BP: 72/50mmHg, W 37kg, heart and lung (¡ª),
abdomen is
flat and soft. He gets little pain on the right side of
the abdomen, Bowel sound
is normal. The
principle of the prescription for today was changed to
anti-diarrhea. Continue to observe the patient¡¯s condition. Such
as Chengpi (tangerine peel), cangshu (atractylodes), Fulin
(poria), etc. One dosage a day and drink by twice, two
days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 24th
of December 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
He says that his lower limb weakness is much better, lame
walking is a little better, but still accompanied by a
duck-gait, can not run. He can climb up 10 steps of the stairs
slowly by himself now, difficulties on squatting down is a
little better. When he squats, he has to stand up slowly by
knees down and hands supported by the ground. He has to turn
over when lying face upward, and using his two hands to climb
with knee-joints supported to rise upward. Thin and white tongue
fur, slight reddish tongue, fine and deep pulse. Prescription:
Such as Dansheng (Salvia), Shoudi (cooked rehmannia), Yujin
(curcuma tuber), etc. One dosage a day and drink by twice, five
days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 27th
of December 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
He says that his lower limb weakness is much better, lame
walking is a little better, but still accompanied by a
duck-gait, can not run. He can climb up 10 steps of the stairs
slowly by himself now, difficulties on squatting down is a
little better. When he squats, he has to stand up slowly by
knees down and hands supported by the ground. He has to turn
over when lying face upward, and using his two hands to climb
with knee-joints supported to rise upward. Slight reddish
tongue, fine and deep pulse. Continue using the same
prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 30th
of December 2006
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Same physical check result as last time. Thin and
white tongue fur, slight reddish tongue, fine and deep pulse.
Continue using the same prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 2nd
of January 2007
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Same physical check result as last time. Thin and
white tongue fur, slight reddish tongue, fine and deep pulse.
Continue using the same prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 5th
of January 2007
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Same physical check result as last time. Thin and
white tongue fur, slight reddish tongue, fine and deep pulse.
Continue using the same prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 8th
of January 2007
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
He says that his lower limb weakness is much better, lame
walking is a little better, but still accompanied by a
duck-gait, still can not run. He can climb up 10 steps of the
stairs slowly by himself now, difficulties on squatting down is
a little better. When he squats, he has to stand up slowly by
knees down and hands supported by the ground. He has to turn
over when lying face upward, and using his two hands to climb
with knee-joints supported to rise upward. Thin and white tongue
fur, slight reddish tongue, fine and deep pulse. Continue using
the same prescription, such as Dansheng (Salvia), Shoudi (cooked
rehmannia), Yujin (curcuma tuber), etc. One dosage a day and
drink by twice, five days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 11th
of January 2007
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Same physical check result as last time. Thin and
white tongue fur, slight reddish tongue, fine and deep pulse.
Continue using the same prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 14th
of January 2007
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue
using the same prescription. Such as Dansheng (Salvia), Shoudi
(cooked rehmannia), Yujin (curcuma tuber), etc. One dosage a day
and drink by twice, five days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 18th
of January 2007
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue
using the same prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 22nd
of January 2007
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue
the same prescription. Such as Dansheng (Salvia), Shoudi (cooked
rehmannia), Yujin (curcuma tuber), etc. One dosage a day and
drink by twice, five days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 26th
of January 2007
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue
using the same prescription.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 30th
of January 2007
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue
using the same prescription. Such as Dansheng (Salvia), Shoudi
(cooked rehmannia), Yujin (curcuma tuber), etc. One dosage a day
and drink by twice, two days.
Dr. Yan zaoming/ Dr. Dai Lei
Date: 3rd
of February 2007
Time: 9:00 a.m.
Today the patient doesn¡¯t complain any other special discomfort.
No aversion to cold. No fever. No headache or dizziness. No
nausea or vomiting. He presents with a good spirit. He has good
appetite and sleep is normal. His bowel movement and urination
are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue
using the same prescription.
Dr. Yan zaoming/ Dr. Dai Lei
