Name: Newton                                                      Sex: Male

Age: 43                                                                 Marital Status: Married

Nationality: India                                                  Date of Admission: Apr.16, 2014

Companion: Nobody

First Medical Record

Date: Apr. 17, 2014                                Time: 11:00 am

Newton, male, 43 years old, had suffered from wasting-thirst for 18 years. He had the following symptoms such as thirst, profuse urine and too much drinking for 18 years. He was allergic to the painkiller. The patient was hospitalized in our hospital with ¡°wasting-thirst¡± for TCM treatment at 20:00 pm on Apr.16, 2014.

Essential for Diagnosis:

1. History of Disease: The patient had thirst, too much drinking and profuse urine for 18 years. He was allergic to the painkiller.

2. When the patient came to our hospital, he was thirsty. He liked cold drinks. He was tired and he felt his body was heavy, especial the left side of his body. He felt the left side of his body was not flexible. And there were obvious stabbing pains over his left shoulder. And sometimes his lower limbs had numbness. His four limbs feared the cold. When we touched his limbs, the limbs were very cold. He was easy to sweat and get a cold. Occasionally he had dizziness, headache and chest pains. His vision was not good. There were many black spots in his vision. He also had gasteremphraxis. His appetite was not good. And there were frequent urinations at night, 4 to 5 times per night. His bowl movement was normal.

3. T: 36.4¡ãC   R: 20 times/minute    P: 90 times/minute   BP: 168/95mmHg

The patient had normal growth, physique and spiritual activity, while with chronic disease face. He cooperated with doctors when the physical examinations were made. There was no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. His neck was soft. His trachea was symmetrical. There was sore swollen throat. The jugular vein was of no engorgement. His chest was also symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 90 times per minute. Heart rate was regular with no murmurs. His abdomen was soft without pressing pains and rebound tenderness. There was no sign of deformity over his spine and four limbs. The sign of meningeal irritation was (-), without the other pathological reflex. His tongue was dark red with tooth marks and thin tongue coating. His pulse was deep and wiry.                                                                                                           

4. Examination: No.

Diagnostic Basis:

TCM: Wasting-thirst

The patient had thirst, profuse urine and too much drinking for 18 years. He preferred to cold drinks. There was blurred vision. And he was easy to sweat. And the urinations were frequent at night.

Western Medicine: Type I Diabetes

                                 The eye disease was caused by Diabetes.

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢ò care, companion, and diabetes diet.

3. Have more medical examination: Blood routine test, Urine routine test and biochemical examination.

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

5. Acupuncture and massage: once a day

6. To apply for the three routine inspections and the following related examination: biochemistry analysis, IMX and HIV.

7. Avoiding wind and cold, relaxing mind and adjusting the diet.

Date: Apr. 18, 2014                                    Time: 9:00 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient was hospitalized in our hospital with ¡°thirst, too much drinking and profuse urine for 18 years¡± for TCM treatment at 20:00 pm on Apr.16, 2014. When the patient came to our hospital, he was thirsty. He liked cold drinks. He was tired and he felt his body was heavy, especial the left side of his body. He felt the left side of his body was not flexible. And there were obvious stabbing pains over his left shoulder. And sometimes his lower limbs had numbness. His four limbs feared the cold. When we touched his limbs, the limbs were very cold. He was easy to sweat and get a cold. Occasionally he had dizziness, headache and chest paisn. His vision was not good. There were many black spots in his vision. He also had gasteremphraxis. His appetite was not good. And there was frequent urination at night, 4 to 5 times per night. His bowl movement was normal, once a day. His tongue was dark red. In the middle of the tongue body, there were cracks, and there were also tooth marks on the edges of the tongue. His tongue coating was thin. His pulse was deep and wiry. According to the TCM four diagnostic methods, it should be ¡°wasting-thirst¡±.

Date: Apr. 19, 2014                                    Time: 9:30 a.m.

Date: Apr. 20, 2014                                    Time: 9:30 a.m.

The patient said the sensation of cold over his four limbs was better. The activity abilities of his left shoulder were also better. There was no urination at night. His tongue was slightly red with thin coating. The pulse was taut and wiry.

Date: Apr. 23, 2014                                    Time: 9:30 a.m.

The patient said the sensation of cold was improved. The sensation of fullness in stomach was better. And the activity abilities of his left shoulder were obviously improved. His appetite was normal. His sleep was not good. Occasionally he woke up at night. There were dreaminess, thirst and polydipsia. But there was no urination at night. Sometimes there was sweating. His tongue was slight red with thin coating. The pulse was taut and wiry.

Date: Apr. 26, 2014                                    Time: 10:00 a.m.

The patient said he still had dreaminess, thirst and polydipsia. But his appetite was good. And the cold sensation of his four limbs had been obviously improved. The other symptoms were the same as before.

Date: Apr. 29, 2014                                    Time: 10:00 a.m.

The patient said the thirst was relieved, only in the morning he drunk much more water. The fullness sensation in stomach disappeared. Good appetite and sleeping. Sometimes he had sweating.

Date: May 1, 2014                                    Time: 9:30 a.m.

The vital signs of the patient were stable this morning.  

Date: May 4, 2014                                    Time: 9:30 a.m.

The patient said his sleeping was bad. In the middle of night there were dizziness and sweating. He felt thirst and he preferred to drink more. He felt that his lower limbs were sensitive and light. His tongue was slightly red with thin coating. The pulse was taut and rapid. To consider the blood sugar of the patient was low, doctor asked him to reduce the dosage of the injection of insulin which he prepared by himself.

Date: May 9, 2014                                    Time: 21:00 p.m.

The blood pressure was 170/80 mmHg. The headache and dizziness had completely gone. The blood sugar was 12.80mmol/L one hour after the meal. And the blood sugar always was around 10.00mmol/L at night. It was a little high.

Date: May 10, 2014                                    Time: 10:00 a.m.

The patient said his sleeping was still not good. In the morning he had sweating. There were no headache, dizziness and thirst. The blood pressure was 150/90 mmHg. The tongue was red with little coating. In the middle of the tongue there were cracks.

Date: May 13, 2014                                    Time: 9:30 a.m.

In the morning when the patient got up he felt slight dizziness. But the sweating was improved. There were twice urinations at night. The blood sugar was stable. There were no palpitations and pains. There was also no numbness over his four limbs.

Date: May 19, 2014                                    Time: 10:00 a.m.

The patient¡¯s conditions were stable and kept turning better. But there was still sweating at night.

Date: May 22, 2014                                    Time: 9:30 a.m.

The patient said he had sweating at night. But his sleeping was good. The tongue was slightly red with thin and white coating. The pulse was taut and wiry.

Date: May 24, 2014                                    Time: 8:00 a.m.

The patient decided to leave our hospital. Summary: His thirst was obviously improved. And the feeling of tiredness and heavy sensation were better. The pains of his left shoulder were also obviously improved. The numbness of lower limbs and the cold sensation of his four limbs disappeared. At night sometimes he still had sweating. The urination and bowel movement were normal. His sleeping was good. The tongue was slightly red with white and thin coating. The pulse was taut and wiry. And He took the herbal tea for 2 months to consolidate the effect.

Doctor¡¯s advice after leaving hospital: