Brief Summary:
Abbas, from Sudan,
has suffered from inhibited urination
for six years, accompanied by numbness of the lower limbs. After
eighteen-day treatment in our hospital, he has achieved obvious
improvement.
¡¡
Record of Hospitalization
Name:
Abbas Sex:
Male
Age:
62 Profession: Doctor
Nationality:
Sudan Marital Status:
Married
Onset
Season:
Spring Date of Admission:
May 25, 2007
Complainer:
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 had 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-ultrasonic, he was diagnosed as ¡°hyperplasia
of enlargement¡±, and prescribed
with corresponding medicine (unknown). His disease
conditions got some improvement. After that, his disease
attacked repeatedly. The patient still suffered from 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. To get traditional Chinese medicine
treatment, he came to our hospital for his MS treatment on May
25, 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 had inhibited urination.
Disease History:
With healthy body over the past. 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 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 got married at the age of 23. He has two sons. His wife and
his sons are all healthy.
Family History:
No family history of special disease.
Physical Examination:
T 36.5¡æ£¬P
78 beats/minute, R 20 times/minute, BP 140/80 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.
His 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 was 80 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.
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.
Other physiological reflex has not been elicited. His tongue was
red with thin and white tongue coating. The pulse was deep and
thready.
Diagnostic examination: Not provided.
First
Diagnosis:
TCM
diagnosis:
Taxation
Strangury
Symptom identification:
Deficiency of the spleen and kidneys, accompanied with damp-heat
brewing.
Western medicine diagnosis: 1. Hyperplasia
of enlargement
2. L4-S1
lumbar
disc protrusion
First
Medical Record
14:30
p.m. May 25, 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
14:30 p.m. on May 25, 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 had 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-ultrasonic, he was
diagnosed as ¡°hyperplasia
of enlargement¡±, and prescribed
with correspondent medicine (unknown). His disease
conditions got some improvement. After that, his disease
attacked repeatedly. The patient still suffered from 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. To get traditional Chinese medicine
treatment, he came to our hospital for his MS treatment on May
25, 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 had inhibited urination.
3. T 36.3¡æ£¬P
78 beats/minute, R 20 times/minute, BP 140/80 mmHg, K 67 kg.
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.
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. There was 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 kidneys.
Therefore, he suffered from weak wilting lumbus and knees,
fatigue spirit and lack of strength. His symptoms were sometimes
serious, and sometimes mild. As deficiency of kidneys with
dampness evil and heat evil, he suffered from
inhibited urination
with strangury. With rough pains continually, his constitution
was weak after long-term illness. His tongue was light with thin
tongue coating. His pulse was thready 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 along with 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.
Western Medicine:
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:
Taxation Strangury
Symptom identification:
Deficiency of the spleen and kidneys, accompanied with damp-heat
brewing.
Western medicine diagnosis: 1. Hyperplasia
of enlargement
2. L4-S1
lumbar
disc protrusion
Plans
for treatment strategy and nursing:
1.
Routine care of traditional Chinese internal medicine.
2.
Grade II care.
3.
Regular diet.
4.
Herbal tea (to supplement the kidneys and invigorate the
lumbus,
quicken the blood and transform stasis, soothe the channels and
quicken the network channels):
one dosage a day and drink twice.
Prescription: Varied Decoction of the Kidneys-Supplementing
Stasis-Quickening.
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 26, 2007 Time: 9:00
a.m.
The patient
complained to Dr. Yan about suffering from inhibited urination
with strangury, accompanied by numbness and pains of the lower
limbs. The examination of ECG was normal. The examination of
B-ultrasonic
showed hyperplasia
of enlargement; six programs of hepatitis B were
normal; the functions of his liver and kidneys were normal, with
normal blood sugar and blood fat. Rheumatoid factor was (+).
Both of his ESR and anti-¡°O¡± were normal.
Examination: T 36.3¡æ£¬P
78 beats/minute, R 20 times/minute, BP 140/80 mmHg.
His heart and lungs was 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.
Hyperplasia of enlargement
2.
Sciatica sciatic
neuralgia
According to the above information, TCM considered diagnosing as
Lin-syndrome (Taxation
Strangury).
Dr.
Yan¡¯s analyzed it was
deficiency of the spleen and kidneys, accompanied with damp-heat
brewing.
Principle of TCM treatment: Supplementing the kidneys and
invigorating the
lumbus, quickening the blood and transforming stasis, soothing the
channels and quickening the network channels.
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 is to take five dosages of the herbal tea
of the same prescription. Acupuncture and massage for once a
day. The patient will have more medical examinations if
necessary.
Date:
May 27, 2007 Time: 9:00
a.m.
The
patient did not complain about any other special discomfort and
told the doctor that he still suffered from
inhibited urination
with strangury, accompanied by numbness and pains of the lower
limbs. His heart and lungs was 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 of his lower limbs was the same as before. His
tongue was light red with thin and white tongue coating. His
pulse was deep and thready. Doctor¡¯s requirement is to take
herbal tea of the same prescription.
Date:
May 28, 2007 Time: 9:00
a.m.
Today
the patient did not complain about any other special discomfort
and told the doctor that his
inhibited urination
with strangury and numbness and pains of the lower limbs all
got some improvement. His heart and lungs 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 of his lower limbs was the same as before. His
tongue was light red with thin and white tongue coating. His
pulse was deep and thready. Doctor¡¯s requirement is to take
herbal tea of the same prescription.
Date:
June 2, 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 lungs 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 of his lower limbs was the same as before. His
tongue was light red with thin and white tongue coating. His
pulse was deep and thready. Doctor¡¯s requirement is to take five
dosages of the herbal tea of the same prescription. One dosage a
day and drink twice.
Date:
June 7, 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 lungs 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 of his lower limbs was the same as before. His
tongue was light red with thin and white tongue coating. His
pulse was deep and thready. Doctor¡¯s requirement is to take the
herbal tea of the same prescription.
Date:
June 12, 2007 Time: 9:00
a.m.
Today
the patient did not complain about any other special discomfort.
His disease condition was stable.
Date:
June 14, 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, and his
numbness and pains of the lower limbs
achieved obvious improvement. His heart and lungs 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 light red with thin and white tongue
coating. His pulse was deep and thready. The patient would
discharge from our hospital today.
