Records of Hospitalization
Name:
Abdul Salim Sex:
Male
Nationality:
Singaporean Age:
9
Marital status:
Unmarried Date
of Admission:
Nov. 13th, 2006
Onset
Season:
Summer
Date of Report:
Nov. 13th,
2006
Complainer of history:
The patient¡¯s father
Reliability:
Reliable
Chief
complaint:
The patient has suffered from lame walking and inability to squat for four years
accompanied by an aggravated duck-gait for two years.
Present illness:
At the end of
2002, the patient had a changing in walking posture without any evident
predisposing cause. He began to slow down his walking speed and standing up
after squatting. At that time, his family neither paid much attention to him,
nor took him to do any examination treatment. In 2004, the patient¡¯s condition
was aggravated. He had difficulties in walking and with imbalance. He had
difficulties in squatting and unable to get up when supine in bed (He needs to
turn over and slowly picks himself up) and walking with duck-gait posture. His
parents checked at the local hospital, but the chromosome examination showed no
abnormality. The diagnosis for the patient was ¡°DMD¡± by MRI and blood test, so
he orally took drugs named "Prednisolone" until now and without further
treatment so far. Two months ago, the patient started to take Chinese medicine
posted by our hospital. The patient has good spirit and sleep, enormous
appetite, thin and white tongue fur, slightly reddish tongue, fine and deep
pulse.
Past
history:
No history of typhoid, tuberculosis and hepatitis. No history of food or
medicine allergy. No history of operation or transfusion. No history of
preventive vaccination provided.
Personal history:
He was born in Singapore, living in a humid environment. No contact history of
schistosomiasis. No addiction to alcohol, smoke or special food. He is calm
temperament and cheerful.
Marital history:
Unmarried.
Family
history:
No family history of special disease.
Physical examination
T 36.2¡æ£¬P
90bpm, R 23bpm, BP: 96/70mmHg, W 36kg.
He is
mid-nourished and normally developed. His mind is clear, chronic face mirroring
difficult condition, languor expression, in a positive position and cooperative
in examination. His skin is moist. No jaundice in the sclera. No superficial
lymph-node enlargement. Bilateral pupils are 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 is not
big. Heart beat 90bpm. Cardiac rhythm was regular. No pathological murmurs of
heart on auscultation. Abdomen is
flat and soft without tenderness or rebound tenderness. Liver and spleen are not
palpable. No percussion pain on renal region. Bowel sound is
normal. No Spinal and pelvic deformity or tenderness. Both upper limbs without
deformity and normal mobility, both lower extremities will see the special
examination. The development of the anus or genital was normal.
Physiological reflex has pathological features without elicited.
Special
examination:
The patient has suffered from lame walking and accompanied by a duck-gait; can
not run, difficulties on stepping up the stairs and squatting down. When he
squats, he has to stand up slowly by knees down and hands supported by the
ground. He has to turn over when lying face upward, and using his two hands to
climb with bent knees supported then slowly rising upward. Both side of
gastrocnemius are hypertrophic and hard.
Accessory examination:
MRI shows ¡°DMD¡±.
First
diagnosis:
TCM diagnosis:
Wei-syndrome (flaccidity syndrome)
Symptom diagnosis:
Spleen and
stomach asthenia; liver and kidney asthenia and phlegm turbidity.
WM
diagnosis:
Progressive
muscular dystrophy (Pseudo-mast); ¡°DMD¡±.
Dr. Yan
Zaoming/ Dr. DaiLei
First Medical Record
9:00
a.m. November 13th, 2006
Abdul Salim,
male, has suffered from lame walking and inability to squat for four years
accompanied by an aggravated duck-gait for two years. He was picked up by our
workers and arrived in Huaihua Red Cross Hospital at November 13th,
2006.
Case
characteristics:
1. The patient
has suffered from lame walking and inability to squat for four years accompanied
by an aggravated duck-gait for two years.
2. At the end
of 2002, the patient had a changing in walking posture without any evident
predisposing cause. He began to slow down his walking speed and standing up
after squatting. At that time, his family neither paid much attention to him,
nor took him to do any examination treatment. In 2004, the patient¡¯s condition
was aggravated. He had difficulties on walking and with imbalance. He had
difficulties on squatting and unable to get up when supine in bed (He needs to
turn over and slowly picks himself up) and walking with duck-gait posture. His
parents checked at the local hospital, but the chromosome examination showed no
abnormality. The diagnosis for the patient was ¡°DMD¡± by MRI and blood test, so
he orally took drugs named "Prednisolone" until now and without further
treatment so far. Two months ago, the patient started to take Chinese medicine
posted by our hospital. The patient has good spirit and sleep, enormous
appetite, thin and white tongue fur, slight reddish tongue, fine and deep pulse.
3. T 36.2¡æ£¬P
90bpm, R 23bpm, BP: 96/70mmHg, W 36kg.
4. He is
mid-nourished and normally developed. His mind is clear, chronic face, languor
expression, in a positive position and cooperative in examination.
5. The patient
has suffered from lame walking and accompanied by a duck-gait; he can not run,
difficulties on stepping up the stairs and squatting down. When he squats, he
has to stand up slowly by knees down and hands supported by the ground. He has
to turn over when lying face upward, and using his two hands to climb with bent
knees supported to rise upward.
6. No thoracic
deformity. Chest percussion noted resonance. Sound of breath was bilaterally
clear on auscultation. No pleural friction rubs.
7. Accessory
examination: Not provided yet.
Diagnostic basis
TCM:
The
patient has suffered from lame walking and inability to squat for four years
accompanied by an aggravated duck-gait for two years. Kidney is congenital
basic, stores essence, governs the bones and engenders marrow. Kidney stores
original Yin and original Yang, if congenital insufficiency, kidney vacuity and
depletion, insufficient essence-blood and bone losses nourish then desiccation
of the bone and vacuity of the marrow. The symptom shows the feet moving out of
controlling of the body, lumbar spine failed to rise, engendered as bone
wilting. On the political dialectic: Dual vacuity of the spleen and kidney,
spleen and stomach are the root of later heaven and the resources of engendering
transformation Qi-blood fluid. Mainly governs muscles and limbs. If spleen and
stomach are vacuous then the five viscera have nothing to support, the grain and
water can not reach the limbs and make muscles atrophied. If it is ahead of the
kidney original yang inadequate, debilitation of the life gate fire, it can not
warm spleen yang and spleen-stomach vacuity cold. The function of intake and
motivation-transformation are abnormal, insufficient of the resources of Qi-blood
fluid engender and transformation, the muscles can not get moistened, so the
muscle of the limbs wilting, soft and lack of strength, start from muscle wilts,
congenital insufficiency, dual Qi and blood vacuity, and can not nourish sinew,
bone and muscle then cause limbs weakness and muscular atrophy. Because of
congenital insufficiency, loss of later heaven nourish and Qi-blood vacuity lead
to five viscera internal injury, bowels and viscera Qi-blood dysfunction, and
made Qi-blood much more vacuous and developing the muscular atrophy, soft and
weakness.
Western medicine basis:
The patient has suffered from lame walking and inability to squat for four years
accompanied by an aggravated duck-gait for two years, can not run, difficulties
on stepping up the stairs and squatting down. When he squats, he has to stand up
slowly by knees down and hands supported by the ground. He has to turn over when
lying face upward, and using his two hands to climb with bent knees supported
then slowly rising upward. The diagnosis from the local hospital is ¡°DMD¡±.
Diagnostic differentiation£ºTCM
differentiated from Bi-syndrome. Late stage of Bi-syndrome, due to the joint
pain in limbs; he can not move because he hasn¡¯t used his limbs for a long time
has similar symptoms as Wei-syndrome, such as thin and wilt, yet the person who
gets Wei-symptom usually has no joint pain on the limbs. On the contrary,
Bi-syndrome usually characterized by aching pain. Because of its etiology and
pathogenesis are different, so do their treatments. These should be
differentiated.
WM
differentiated from amyotrophic lateral sclerosis:
Most patients get the disease between the ages of 30 to 50. This kind of disease
has a slow onset. Most of the patient start onset from one side of the body
limbs, later on it develops into both sides. The common onset pattern starts
from the upper limbs, showing inflexible movement and muscular dystrophy,
indicated as "claw hand", and then gradually developing to the forearm, upper
arm and shoulder muscles, with aggravation of the muscular dystrophy, weakness
of the limbs leading to paralysis. This should be distinguished.
First
diagnosis
TCM
diagnosis:
Wei-symptom (flaccidity syndrome)
Symptom diagnosis:
Spleen and
stomach asthenia; liver and kidney asthenia and phlegm turbidity.
WM
diagnosis:
Progressive
muscular dystrophy (Pseudo-mast); ¡°DMD¡±.
Plan
of the treatment:
1. On routine
care of traditional Chinese internal medicine
2. On grade II
care
3. Nurse
4. Low salt,
sugar and fat diet
5. Herbal tea:
Boost Qi and fortify the spleen, supplement the kidney and strengthening the
sinew. Such as Guiban (tortoise plastron), Baishao (Paeonia Lactiflora),
lujiaoshuang (Degelatinated Deerhorn), etc. One dosage a day and drink by twice.
6. Massage
once a day
7. Acupuncture
once a day
8. Have more
medical examinations if necessary
Dr. Yan
Zaoming/ Dr. DaiLei
¡¡
Date:
14th of November 2006
Time:
9:00 a.m.
Deputy
Chief Physician rounds
This morning is Deputy Chief Physician Yan
Zaoming¡¯s ward-round. The patient complained that his lower limb weakness, he
can not run, difficulty squatting, unstable walking accompanied by a duck-gait.
Examination: T 36.2¡æ£¬P
90bpm, R 23bpm, BP: 96/70mmHg, W 36kg. The patient suffered from lame walking
and accompanied by a duck-gait; he can not run, difficulties on stepping up the
stairs and squatting down. When he squats, he has to stand up slowly by knees
down and hands supported by the ground. He has to turn over when lying face
upward, and using his two hands to climb with bent knees supported to rise
upward. Dr. Yan analyzed as the following:
1. The patient
has suffered from lame walking and inability to squat for four years accompanied
by an aggravated duck-gait for two years.
2. Body check
as stated above.
3. The
diagnosis from the local hospital: Progressive muscular dystrophy (Pseudo-mast),
¡°DMD¡±. According to the materials from up stated, TCM considered it as Wei-symptom.
Wei-symptom is a kind of disease with limbs atony, soft-weakness, can not move
freely or accompanied with muscular atrophy.
In
clinical terms:
It often seen the lower limb wilting and weakness, and also named ¡°wilting-bi¡¯.
Suwen-Angry Discussion
pointed out that, ¡°due to wet, first as warp, large sinew is soft-shorten, small
sinew is loose-lengthen, soft-shorten is hypertonicity and loose-lengthen is
wilt (Wei).¡± Its causes are very complicated. The external cause is warm-heat
evil with toxicity, affect-mind internal damage, tired during eating and
drinking, insufficient of earlier heaven (be born congenitally deficient), and
excessive sexual activities. Injuries from falls, touching neurotoxicity drugs
and so on can lead to five viscera damages. Insufficient of essence and liquid,
depleted Qi-blood, sinews, vessels and muscles deprived of nourishment, can
finally lead to Wei-symptom (flaccidity symptom). The treatment of Wei-syndrome
should be focused on the meridian of yangming because Yangming is the sea of the
Zang-Fu organs, and also governs the moistening. The main sinews and the main
sinews charge the born then invigorate the body. Body liquid, essence-blood both
come from spleen and stomach. If the movement and transformation of the spleen
and stomach is not strong, or insufficiency of the source of transforming the
essence blood, sinew and vessel deprived of nourishment leads to useless wei-bi
(Wilt-low limbs).
Dialectical:
Spleen and
stomach asthenia; liver and kidney asthenia and phlegm turbidity. Treatment
principle: Boost Qi and fortify the spleen, supplement the kidney and strengthen
the sinew, sweep phlegm and open the orifices. Prescription: Add or reduce
medicine of Two Immortals Decoction of kidney-enrich: Such as Guiban (tortoise
plastron), Baishao (Paeonia Lactiflora), lujiaoshuang (Degelatinated Deerhorn),
etc. One dosage a day and drink by twice, 3 days. Acupuncture and massage once a
day, and have more medical examinations if necessary.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
15th of November 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any special discomfort. He complained that his lower
limb weakness, lame walking and accompanied by a duck-gait; he can not run,
difficulties on stepping up the stairs and squatting down. No aversion to cold.
No fever. No headache or dizziness. No nausea or vomiting. He presents with a
good spirit. His sleep is good. His bowel movement and urination are normal.
Thin and white tongue fur, slight reddish tongue, fine and deep pulse.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
16th of November 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any special discomfort. He complained that his lower
limb still weakness, lame walking and accompanied by a duck-gait, can not run,
difficulties on stepping up the stairs and squatting down. When he squats, he
has to stand up slowly by knees down and hands supported by the ground. He has
to turn over when lying face upward, and using his two hands to climb with bent
knees supported to rise upward. No aversion to cold. No fever. No headache or
dizziness. No nausea or vomiting. He presents with a good spirit. He has
enormous appetite and sleep is good. His bowel movement and urination are
normal. Thin and white tongue fur, slight reddish tongue, fine and deep pulse.
Give the same prescription, 3 more days.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
19th of November 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any special discomfort. He complained that his lower
limb still weakness, but a little better, lame walking and accompanied by a
duck-gait, can not run, difficulties on stepping up the stairs and squatting
down. When he squats, he has to stand up slowly by knees down and hands
supported by the ground. He has to turn over when lying face upward, and using
his two hands to climb with bent knees supported to rise upward. No aversion to
cold. No fever. No headache or dizziness. No nausea or vomiting. He presents
with a good spirit. His sleep was good. His bowel movement and urination were
normal. Thin and white tongue fur, slight reddish tongue, fine and deep pulse.
Give the same prescription, 5 more days. Such as Shoudi (cooked rehmannia),
Suoyang (Cynomorium songaricum), lujiaoshuang (Degelatinated Deerhorn), etc. One
dosage a day and drink by twice, 5 days.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
22nd of November 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any special discomfort. He complained that his lower
limb weakness is a little better, lame walking and accompanied by a duck-gait;
he can not run, difficulties on stepping up the stairs and squatting down. When
he squats, he has to stand up slowly by knees down and hands supported by the
ground. He has to turn over when lying face upward, and using his two hands to
climb with bent knees supported to rise upward. No aversion to cold. No fever.
No headache or dizziness. No nausea or vomiting. He presents with a good spirit.
His sleep was good. His bowel movement and urination were normal. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue using the same
prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
25th of November 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any special discomfort. He says that his lower limb
weakness is much better, but still lame walking and accompanied by a duck-gait;
he can not run, difficulties on stepping up the stairs and squatting down. When
he squats, he has to stand up slowly by knees down and hands supported by the
ground. He has to turn over when lying face upward, and using his two hands to
climb with knee-joints supported to rise upward. No aversion to cold. No fever.
No headache or dizziness. No nausea or vomiting. He presents with a good spirit.
He has enormous appetite and sleep good. His bowel movement and urination are
normal. Thin and white tongue fur, slight reddish tongue, fine and deep pulse.
Continue using the same prescription, 5 more days. Such as Shoudi (cooked
rehmannia), Suoyang (Cynomorium songaricum), Guijiao (tortoise plastron glue),
etc. One dosage a day and drink by twice, 5 days.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
28th of November 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other discomfort. He says that his lower limb
weakness is much better, lame walking is a little better, but still accompanied
by a duck-gait, can not run, difficulties on stepping up the stairs and
squatting down. When he squats, he has to stand up slowly by knees down and
hands supported by the ground. He has to turn over when lying face upward, and
using his two hands to climb with knee-joints supported to rise upward. Thin and
white tongue fur, slight reddish tongue, fine and deep pulse. Continue using the
same prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
1st of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other discomfort. He says that his lower limb
weakness is much better, lame walking is a little better, but still accompanied
by a duck-gait, can not run. He can climb up 10 steps of the stairs by
somebody¡¯s help, difficulties on squatting down. When he squats, he has to stand
up slowly by knees down and hands supported by the ground. He has to turn over
when lying face upward, and using his two hands to climb with knee-joints
supported to rise upward. Thin and white tongue fur, slight reddish tongue, fine
and deep pulse. Continue using the same prescription, 5 more days.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
4th December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other discomfort. He says that his lower limb
weakness is much better, lame walking is a little better, but still accompanied
by a duck-gait, can not run. He can climb up 10 steps of the stairs by
somebody¡¯s help, difficult on squatting down. When he squats, he has to stand up
slowly by knees down and hands supported by the ground. He has to turn over when
lying face upward, and using his two hands to climb with knee-joints supported
to rise upward. Thin and white tongue fur, slight reddish tongue, fine and deep
pulse.
Continue using
the same prescription. Such as Guijiao (tortoise plastron glue), Suoyang (Cynomorium
songaricum), lujiaoshuang (Degelatinated Deerhorn), etc. One dosage a day and
drink by twice.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
7th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other discomfort. He says that his lower limb
weakness is much better, lame walking is a little better, but still accompanied
by a duck-gait, can not run. He can climb up 10 steps of the stairs by
somebody¡¯s help, difficulties on squatting down. When he squats, he has to stand
up slowly by knees down and hands supported by the ground. He has to turn over
when lying face upward, and using his two hands to climb with knee-joints
supported to rise upward. Thin and white tongue fur, slight reddish tongue, fine
and deep pulse. Continue using the same prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
10th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other discomfort. He says that his lower limb
weakness is much better, lame walking is a little better, but still accompanied
by a duck-gait, can not run. He can climb up 10 steps of the stairs by
somebody¡¯s help, difficulties on squatting down. When he squats, he has to stand
up slowly by knees down and hands supported by the ground. He has to turn over
when lying face upward, and using his two hands to climb with knee-joints
supported to rise upward. Thin and white tongue fur, slight reddish tongue, fine
and deep pulse. Continue using the same prescription. Such as Yujin (curcuma
tuber), Dansheng (Salvia), Shengdi (fresh rehmannia), etc.
Dr. Yan
zaoming/ Dr. Dai Lei
¡¡
Stage Summary
Date:
12th of December 2006
Time: 9:00 a.m.
The patient,
Abdul Salim, a 10-year-old male, has suffered from lame walking and inability to
squat for four years accompanied by an aggravated duck-gait for two years. He
has admitted in our Red Cross Hospital about 30 days since November 11th,
2006.
Admission situation:
The patient
has suffered from lame walking and inability to squat for four years accompanied
by an aggravated duck-gait for two years. No headache or dizziness. No nausea or
vomiting. No aversion to cold. No fever. He presents with a good spirit. His
appetite and sleep is good. His bowel movement and urination are normal.
Physical
examination:
T 36.2¡æ£¬P
90bpm, R 23bpm, BP: 96/70mmHg, W 36kg, heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
The patient has suffered from lame walking and accompanied by a duck-gait; he
can not run, difficulties on stepping up the stairs and squatting down. When he
squats, he has to stand up slowly by knees down and hands supported by the
ground. He has to turn over when lying face upward, and using his two hands to
climb with bent knees supported then slowly rising upward. Thin and white tongue
fur, slight reddish tongue, fine and deep pulse. MRI: Progressive muscular
dystrophy ¡°DMD¡±.
Admission diagnosis:
TCM diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom diagnosis:
Spleen and
stomach asthenia; liver and kidney asthenia.
WM
diagnosis:
Progressive
muscular dystrophy; ¡°DMD¡±.
Diagnosis and treatment process:
After the
patient was admitted in our hospital, we gave him Chinese medicine to boost Qi
and fortify the spleen, supplement the kidney and strengthen the sinew. The
prescription is Two Immortals Decoction of kidney-enrich, adding or reducing the
medicine. One dosage a day and drink by twice. Acupuncture and massage once a
day. His health condition improved due to the combined treatment.
Present condition:
His lower limb
weakness and lame walking are much better, but still can not run. He can climb
up about 10 steps of the stairs by himself now. Difficulty on squatting down is
a little better. When he squats, he has to stand up slowly by knees down and
hands supported by the ground. He has to turn over when lying face upward, and
using his two hands to climb with knee-joints supported to rise upward.
Present diagnosis:
TCM diagnosis:
Wei-syndrome (flaccidity syndrome)
Symptom diagnosis:
Spleen and
stomach asthenia; liver and kidney asthenia.
WM
diagnosis: ¡°Progressive
muscular dystrophy¡±, DMD.
Plan
of the treatment:
1. In order to
improve more of his disease condition, we suggested the patient to extend 30
days treatment.
2. Continue
the combined treatment of Chinese medicine, acupuncture, massage and functional
training.
Dr. Yan
zaoming/ Dr. Dai Lei
Suoyang (Cynomorium
songaricum)
One dosage a
day and drink by twice, 5 days.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
13th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other discomfort. He says that his lower limb
weakness is much better, lame walking is a little better, but still accompanied
by a duck-gait, can not run. He can climb up 10 steps of the stairs slowly by
himself now, difficulties on squatting down is a little better. When he squats,
he has to stand up slowly by knees down and hands supported by the ground. He
has to turn over when lying face upward, and using his two hands to climb with
knee-joints supported to rise upward. Thin and white tongue fur, slight reddish
tongue, fine and deep pulse. Strengthen the functional training. Continue using
the same prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
16th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other discomfort. He says that his lower limb
weakness is much better, lame walking is a little better, but still accompanied
by a duck-gait, can not run. He can climb up about 10 steps of the stairs slowly
by himself, difficulties on squatting down is a little better. When he squats,
he has to stand up slowly by knees down and hands supported by the ground. He
has to turn over when lying face upward, and using his two hands to climb with
knee-joints supported to rise upward. Thin and white tongue fur, slight reddish
tongue, fine and deep pulse. Strengthen the patient¡¯s functional training.
Continue using the same prescription. Such as Suoyang (cynomorium songaricum),
Shoudi (cooked rehmannia), Yujin (curcuma tuber), etc. One dosage a day and
drink by twice, 5 days.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
19th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other discomfort. He says that his lower limb
weakness is much better, lame walking is a little better, but still accompanied
by a duck-gait, can not run. He can climb up about 10 steps of the stairs slowly
by himself, difficulties on squatting down is a little better. When he squats,
he has to stand up slowly by knees down and hands supported by the ground. He
has to turn over when lying face upward, and using his two hands to climb with
knee-joints supported to rise upward. Thin and white tongue fur, slight reddish
tongue, fine and deep pulse. Strengthen the functional training. Continue using
the same prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
20th of December 2006
Time: 9:00 a.m.
Today the
patient complains that he has two times diarrhea this morning. He presented with
a bad spirit. His urination is normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
He has obvious pain on the right side of the abdomen, no rebound tenderness.
Liver and spleen were not palpable. No
percussion pain on renal region. Bowel sound was
normal. Urgency check: Blood RT result: WBC 4.8¡Á109/L,
C-RA% 70.0%, RBC 4.83¡Á1012/L.
Basically ruled out the diagnosis of acute appendicitis, and give the patient
No. 4 Fupaisuan capsules. Two tablets a time and two times a day. Observe the
patient¡¯s disease condition.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
21st of December 2006
Time: 9:00 a.m.
Today the patient complains that he still had
diarrhea two times last night. He presented with a bad spirit, sleep and a
little bad appetite. His urination is normal. No aversion to cold. No fever. No
headache or dizziness. No nausea or vomiting. Physical check: T 36.6¡æ£¬P
78bpm, R 20bpm, BP: 72/50mmHg, W 37kg, heart and lung (¡ª),
abdomen is
flat and soft. He gets little pain on the right side of the abdomen,
Bowel sound is normal. The principle
of the prescription for today was changed to anti-diarrhea. Continue to observe
the patient¡¯s condition. Such as Chengpi (tangerine peel), cangshu (atractylodes),
Fulin (poria), etc. One dosage a day and drink by twice, two days.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
24th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
He says that his lower limb weakness is much better, lame walking is a little
better, but still accompanied by a duck-gait, can not run. He can climb up 10
steps of the stairs slowly by himself now, difficulties on squatting down is a
little better. When he squats, he has to stand up slowly by knees down and hands
supported by the ground. He has to turn over when lying face upward, and using
his two hands to climb with knee-joints supported to rise upward. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Prescription: Such as
Dansheng (Salvia), Shoudi (cooked rehmannia), Yujin (curcuma tuber), etc. One
dosage a day and drink by twice, five days.
Dr. Yan
zaoming/ Dr. Dai Lei
¡¡
Date:
27th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
He says that his lower limb weakness is much better, lame walking is a little
better, but still accompanied by a duck-gait, can not run. He can climb up 10
steps of the stairs slowly by himself now, difficulties on squatting down is a
little better. When he squats, he has to stand up slowly by knees down and hands
supported by the ground. He has to turn over when lying face upward, and using
his two hands to climb with knee-joints supported to rise upward. Slight reddish
tongue, fine and deep pulse. Continue using the same prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
¡¡
Date:
30th of December 2006
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Same physical check result as last time. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue using the same
prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
2nd of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Same physical check result as last time. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue using the same
prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
5th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Same physical check result as last time. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue using the same
prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
8th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
He says that his lower limb weakness is much better, lame walking is a little
better, but still accompanied by a duck-gait, still can not run. He can climb up
10 steps of the stairs slowly by himself now, difficulties on squatting down is
a little better. When he squats, he has to stand up slowly by knees down and
hands supported by the ground. He has to turn over when lying face upward, and
using his two hands to climb with knee-joints supported to rise upward. Thin and
white tongue fur, slight reddish tongue, fine and deep pulse. Continue using the
same prescription, such as Dansheng (Salvia), Shoudi (cooked rehmannia), Yujin
(curcuma tuber), etc. One dosage a day and drink by twice, five days.
Dr. Yan
zaoming/ Dr. Dai Lei
¡¡
Date:
11th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Same physical check result as last time. Thin and white
tongue fur, slight reddish tongue, fine and deep pulse. Continue using the same
prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
14th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white tongue fur, slight
reddish tongue, fine and deep pulse. Continue using the same prescription. Such
as Dansheng (Salvia), Shoudi (cooked rehmannia), Yujin (curcuma tuber), etc. One
dosage a day and drink by twice, five days.
Dr. Yan
zaoming/ Dr. Dai Lei
¡¡
Date:
18th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white tongue fur, slight
reddish tongue, fine and deep pulse. Continue using the same prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
¡¡
Date:
22nd of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white tongue fur, slight
reddish tongue, fine and deep pulse. Continue the same prescription. Such as
Dansheng (Salvia), Shoudi (cooked rehmannia), Yujin (curcuma tuber), etc. One
dosage a day and drink by twice, five days.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
26th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white tongue fur, slight
reddish tongue, fine and deep pulse. Continue using the same prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
¡¡
Date:
30th of January 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white tongue fur, slight
reddish tongue, fine and deep pulse. Continue using the same prescription. Such
as Dansheng (Salvia), Shoudi (cooked rehmannia), Yujin (curcuma tuber), etc. One
dosage a day and drink by twice, two days.
Dr. Yan
zaoming/ Dr. Dai Lei
Date:
3rd of February 2007
Time: 9:00 a.m.
Today the
patient doesn¡¯t complain any other special discomfort. No aversion to cold. No
fever. No headache or dizziness. No nausea or vomiting. He presents with a good
spirit. He has good appetite and sleep is normal. His bowel movement and
urination are normal. Physical check: Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
Same examination on the lower limb as before. Thin and white tongue fur, slight
reddish tongue, fine and deep pulse. Continue using the same prescription.
Dr. Yan
zaoming/ Dr. Dai Lei
