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Brief Summary: On Jun. 7, 2009, S from Kosovo, who has suffered from vitiligo, was hospitalized in our hospital. She has achieved some improvement after 27 days TCM treatment here.

 

Record of Hospitalization

Name: S                                                                                                                       Birthplace: Kosovo

Sex: Female                                                                                                                  Profession: Businessman

Age: 38                                                                                                                        Date of Admission: Jun. 7, 2009

Nationality: Kosovo                                                                                                    Date of Record: Jun. 7, 2009

Marital Status: Married                                                                                               Onset Season: Slight heat

Complainer: The patient herself

 

First Medical Record

Date: Jun. 7, 2009                                        Time: 1: 00 a. m.

S, a 38-year-old female, has suffered from white patches all over the body for 32 years and depravation of the condition for 13 years. She was hospitalized in our hospital at 1: 00 a. m. on Jun. 7, 2009.

Essentials for Diagnosis:

1. The patient has suffered from white patches all over the body for 32 years and depravation of the condition for 13 years.

2. There were small white patches on her back without obvious reasons when she was 6 years old. Then gradually the white patches spread to all over her body. And there was no any improvement after the treatment for many years. Her condition became worse when she gave a birth at 25 years old. She felt scorching hot and slightly itching when the white patches were burnt. There were big white patches on her neck, chest and buttocks. The biggest one was in size of 30©M ¡Á 40©M. So she came to our hospital for further treatment at 1: 00 a. m. on Jun. 7, 2009.

3. T 36.2¡æ, P 80 times/minute, R 20 times/minute, BP 110/60mmHg.

4. She grew normally with common nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. Her body was in a positive posture and she was cooperative with clear mind.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. There were generalized white patches all over the body. She felt scorching hot and slightly itching when the white patches were burnt. There were big white patches on her neck, chest and buttocks. The biggest one was in size of 30©M ¡Á 40©M.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient has suffered from white patches all over the body for 32 years and depravation of the condition for 13 years. There were big white patches on her neck, chest and buttocks. The biggest one was in size of 30©M ¡Á 40©M. Her tongue was pale red. Her tongue coating was pale yellow with tooth marks on the edges of the tongue. Her pulse was thready, rapid and slippery. According to the symptoms of the tongue and pulse, she was diagnosed with white patches.

Western Medicine: The patient has suffered from white patches all over the body for 32 years and depravation of the condition for 13 years. There were big white patches on her neck, chest and buttocks. The biggest one was in size of 30©M ¡Á 40©M. She was diagnosed with vitiligo in the local hospital.

Diagnostic Differentiation:

TCM: The patient¡¯s vitiligo should be differentiated from chronic eczema. If one suffers from chronic eczema, there are the symptoms of red spots and scales. But The skin lesions are mostly limited to flexor aspect, accompanied with the symptoms of sharp itch, pigmentation, scant scales. The colour of skin lesions is not silver-white and there is no bleeding when the lesions are scratched. So they are not difficult to be distinguished.

Western Medicine: The patient¡¯s vitiligo should be differentiated from exfoliative dermatitis. Both of the diseases will result in abnormal peeling of the skin. However, exfoliative dermatitis is mainly characterized by tidal reddening and peeling of the skin all over the body, but with no silver-white scales. So they are not difficult to be distinguished.

First Diagnosis:

TCM diagnosis: White patches

Symptom identification: spleen qi vauity and insufficiency of yin blood.

Western Medicine diagnosis: Vitiligo

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Common diet.

4. TCM treatment strategy: boost qi, fortify the spleen, enrich yin, clear heat, nourish the blood and dispel wind.

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

6. Acupuncture and massage: once a day.

7. Have more medical examinations if necessary.

 

Date: Jun. 7, 2009                           

The patient has suffered from white patches all over the body for 32 years and depravation of the condition for 13 years. There were small white patches on her back without obvious reasons when she was 6 years old. Then gradually the white patches spread to all over her body. And there was no any improvement after the treatment for many years. Her condition became worse when she gave a birth at 25 years old. She felt scorching hot and slightly itching when the white patches were burnt. Besides, she had the symptoms of tiredness, poor food intake and aversion to cold. There were big white patches on her neck, chest and buttocks. The biggest one was in size of 30©M ¡Á 40©M. Her tongue was pale red. Her tongue coating was pale yellow with tooth marks on the edges of the tongue. Her pulse was thready, rapid and slippery. The prescription was as follows: chuanxiong (ligusticum root), danpi (moutan root bark), etc. 3 dosages in total.

 

Date: Jun. 8, 2009                           

The examinations of the function of the liver and kidneys, E₄A, urine analysis, etc. were normal. Her diet was not good. Her sleep, urine and bowel movement were normal. Continue to take the same prescription.

 

Date: Jun. 9, 2009

Her general condition was good. The former prescription was changed a little. 5 dosages in total. Meanwhile, Professor Zhang prescribed some herbal medicine for her for external application. Twice a day.

 

Date: Jun. 14, 2009

Her diet was not good. Yesterday she had menstruation, but there were no pains of the waist and abdomen. The menstrual flow was normal. The prescription was changed as follows: gancao (licorice root), fangfeng (ledebouriella), etc. 5 dosages in total.

 

Date: Jun. 19, 2009

The skin of her hands became red due to exposure to the sunshine. Meanwhile, she felt scorching hot and slight pains. The doctor gave her some medicine for external application.

 

Date: Jun. 24, 2009

Her diet was increasing. Some white patches on her back became pale red. Her arms and the back of her hands turned red due to sunniness, but she didn¡¯t feel the pains. Meanwhile, there was some improvement of scorching hot. The prescription was changed as follows: fangfeng (ledebouriella), buguzhi (psoralea seed), etc. 5 dosages in total.

 

Date: Jun 30, 2009

The symptoms of cold, cough, dizziness and headache disappeared. The colour of some white patches became light. The prescription was changed as follows: dangshen (codonopsis root), danshen (salvia root), etc. 3 dosages in total.

 

Date: Jul. 3, 2009

The colour of the white patches on the neck, chest and the upper limbs became light after the comprehensive treatment including herbal tea, acupuncture, massage and herbal medicine for external application. The patient decided to leave the hospital with taking herbal tea back to home for continuous treatment.

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