TCM China:  

Record of Herbal Treatment Of Jonathan from England, Improvement Of Skin Problem
 

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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).

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