Brief Summary: On Sep. 7, 2009, Mr. X from Spain, who has suffered from neurasthenia, accompanied with the symptoms of the spirit stress and tense muscles for 10 years, the condition became worse in the latest 1 year, was hospitalized in our hospital. He has achieved obvious improvement after 17 days TCM treatment here. The patient's sleeping has been improved obviously. He could sleep for 7 to 8 hours every night. The spirit stress, dizziness and headache have been improved a lot. Also, the symptoms of sleepiness and unconsciousness have improved obviously. The condition of the tense muscles also disappeared. He had an increasing diet. His spirit condition got good improvement.

Name: Mr. X                                                                                                        Birthplace: Spain

Sex: Male                                                                                                             Age: 31

Nationality: Spanish                                                                                             Date of Admission: Sep. 7, 2009

Marital Status: Unmarried                                                                                   Date of Record: Sep. 7, 2009

Complainer: The patient herself.                                                                           Onset Season: Moderate Heat

The case was recorded by TCM group.

First Medical Record

Date: Sep. 7, 2009                                          Time: 22: 00 p. m.

Mr. X, a 31-year-old male, has suffered from neurasthenia, accompanied with the spirit stress and tense muscles for 10 years. The condition became worse in the latest 1 year. He was hospitalized in our hospital for treatment at 22:00 p.m. on Sep. 7, 2009.

Essentials for Diagnosis:

1. The patient has suffered from the spirit stress and tense muscles for 10 years. The condition became worse in the latest 1 year.

2. The patient's parents were strict with him, when he was a child. Since the long term of stress, the patient began to have the symptoms of spirit stress and tense muscles from 10 years ago. And there were symptoms of headache, sleepless and dizziness. At the same time, his memory was declining. He felt fatigue. His spirit was low. He could only sleep for about 4 to 5 hours every night. However, the patient did not pay much attention with these symptoms before. During the latest 1 year, the patient felt that his condition worsened. To pursue improvement, he came to our hospital for the treatment on Sep. 7, 2009.

3. T 36.2≧, P 88 times/minute, R 20 times/minute, BP 120/70mmHg.

4. He grew normally with medium nutrition. His mind is conscious. He had an expression of chronic illness and tiredness. His body was cooperative with his 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. The patient had the symptoms of spirit stress and tense muscles. He got tired easily. Sometimes there were symptoms of headache, sleepless and dizziness. He could only sleep for about 4 to 5 hours every night. His memory was declining. The tongue body was reddish. His tongue coating was yellowish and slippery. His pulse was thready. According to the symptoms of the tongue and pulse, he was diagnosed with depression pattern.

7. Accessory examination: none.

Diagnostic Basis:

TCM: The patient has typical symptoms of the spirit stress and tense muscles for 10 years. The condition worsened in the latest 1 year. There were symptoms of headache, sleepless and dizziness. He could only sleep for about 4 to 5 hours every night. His memory was declining. The tongue body was reddish. His tongue coating was yellowish and slippery. His pulse was thready. According to the symptoms of the tongue and pulse, from the traditional Chinese medicine treatment theory, his case was caused by qi stagnation and depression, and he was diagnosed with depression pattern.

Western Medicine: The patient has typical symptoms of the spirit stress and tense muscles for 10 years. The condition worsened in the latest 1 year. There were symptoms of headache, sleepless and dizziness. He could only sleep for about 4 to 5 hours every night. His memory was declining. He was diagnosed with nervosism.  

Diagnostic Differentiation:

TCM: The patient's depression pattern should be differentiated from Mania. Mania mainly appears on young person. And there are no obvious differences of morbidity between male and female. However, the symptom of anoia could not disappear by the mania patient himself. So they are not difficult to be distinguished.

Western Medicine: Nervosism should be differentiated from heavy psychosis. Nervosism can be seen at the first stage of Schizophrenia and Depression, also appears on the breakout and remission stage. Heavy psychosis is a kind of disease that the patient could have nervosism at the earlier stage. The patient could not pay much attention to his health himself and ask for treatment actively. And there are symptoms mental problems accordingly. So they are not difficult to be distinguished.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Depression pattern

Symptom identification: Liver depression and obstruction of the network channels, lack of nourishment of the sinews and vessels.

Western Medicine: Nervosism

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade  = 3 \* ROMAN III care.

3. Common diet.

4. Treatment strategy: course the liver and resolve depression, soft the sinews and quicken the network channels.

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

6. Acupuncture: once per day.

7. Massage: once a day.

 8. Have more medical examinations if necessary.

Date: Sep. 8, 2009                                          Time: 11: 00 a. m.

The patient had the symptoms of spirit stress and tense muscles. He got tired easily. Sometimes there were symptoms of headache, sleepless and dizziness. He could only sleep for about 4 to 5 hours every night and easily waked. His memory was declining. The tongue body was reddish. His tongue coating was yellowish and slippery. His pulse was thready. According to the symptoms of the tongue and pulse, he was diagnosed with depression pattern. His case was due to liver depression and obstruction of the network channels, lack of nourishment of the sinews and vessels. Our treatment strategy is to course the liver and resolve depression, soft the sinews and quicken the network channels. 4 dosages in total.

Date: Sep. 11, 2009                                           Time: 10: 00 a. m.

The patient's spirit stress relieved a little. His sleep became better. He could sleep for 5 to 6 hours every night. The symptoms of headache and dizziness reduced a little. He had an increasing appetite. His spirit got better. His tongue was pink. The tongue coating was thin and white. His pulse was thready. The prescription was the same with Sep. 8th. 6 dosages in total.

Date: Sep. 16, 2009                                           Time: 10: 00 a. m.

The patient's spirit stress has got obvious improvement. The symptom of tense muscles on the whole body reduced. The symptom of headache has stopped. The symptom of dizziness has decreased. He had a good sleeping for 7 to 8 hours every night. His mind and thinking became clearer. His diet increased. His spirit was good. But he felt dry mouth. His tongue was pink. The tongue coating was thin and white. His pulse was thready. The prescription was changed a little. 5 dosages in total.

Date: Sep. 21, 2009                                           Time: 10: 00 a. m.

The patient's sleeping has got obvious improvement. The symptoms of spirit stress, dizziness and headache have reduced a lot. The condition of tense muscles disappeared. His diet increased. His spirit became better. The tongue and pulse were normal. The prescription was the same with Sep. 16th. 3 dosages in total.

Date: Sep. 14, 2009                                           Time: 10: 00 a. m.