Name: Gerald                                                                                                     Sex: Male

Age: 47                                                                                                              Marital Status: Married

Nationality: Austrian                                                                                           Date of Admission: Jan. 15, 2011

Companion: Alone

First Medical Record

Date: Jan. 17, 2011                                      Time: 10:00 am

This 47-year-old gentleman had been suffering from austion for more than one year. He had been feeling overburden in his work and lassitude for one year. Half a year later, his condition became severe, and he was been hospitalized for treatment. The patient was hospitalized in our hospital for TCM treatment on Feb. 9, 2011.

Essential for Diagnosis:

1. The patient had been suffering from fatigue and lassitude for one year, and half a year later, his condition became severe, and he was hospitalized for treatment.

2. The patient complained of over-fast pace of life and overburden of work, which was leading to fare of work and fatigue. In the recent one year, his symptoms were very evident, especially in the recent half a year. The patient, himself felt very fragility and could not resist much work load. When the patient was hospitalized in our hospital, he felt very fragility and could not resist much work load. His tongue coating was slightly yellowish. His mouth was not dry and bitter. He had no dizziness or headache. His bowel movement and urination was good. His sleep was not good. His pulse was thready and rapid.

3. T: 36.5¡ãC   R: 20 times/minute    P: 80 times/minute   BP: 140/80 mmHg

4. His spirit activity was good. He grew normally. His diet was of common nutrition. He had fine sense. The motion of his four limbs was flexible. He had sanguine facial complexion with a slightly plump body. Sound of breathing in the lungs was clear, without any rhonchi. The formation and size of his thorax were normal. His abdomen was soft. There was no enlargement of his liver and spleen. There were no abdominal jugular reflux sign and Murphy¡¯s sign. There were no pressing pains and rebound tenderness. There were no abnormal changes in his stomach and intestines. There were no pains when tunking his kidney areas.

TCM: The patient felt easily fatigued and lassitude. His tongue was slightly yellowish. There were no dryness and bitterness in his mouth. He suffered no pains, tinnitus and headache. His bowel movement and urination were normal. So his condition could be diagnosed as depressive disorder.    

Western Medicine: The patient felt easily fatigued and lassitude. His tongue was slightly yellowish. There were no dryness and bitterness in his mouth. He suffered no pains, tinnitus and headache. His bowel movement and urination were normal. Therefore, his condition could be diagnosed as fatigue syndrome.

Diagnostic Differentiation:

TCM: The patient¡¯s condition should be differentiated with zangzao (dirty dry) syndrome. Zangzao syndrome often happens on young women, which is caused by some mental factors and occurs intermittently. Therefore, it was easy to differentiate them.

Western Medicine: His condition should be differentiated from epilepsy. As to epilepsy, it occurs relating to the abnormal, excessive or hypersynchronous neuronal activity in the brain. So, it was easy to differentiate them.

First Diagnosis:

TCM: Depressive disorder.

Symptom identification: the deficiency of heart, spleen and qi, stagnation of qi transforming into fire.

Western Medicine: Fatigue syndrome.  

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢ò care.

3. Common diet.

4. Pathogenesis: the deficiency of heart, spleen and qi, stagnation of qi transforming into fire. 

5. TCM strategy: to free the liver and remove stagnation of qi as well as to invigorate the spleen and nourish the kidneys.

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

7. Acupuncture and massage: once a day

Date: Jan. 18, 2011                                        Time: 10:00 am

This morning, Professor Yang Qingzhi paid a visit to the patient. The patient said he was very exhausted and feared to work and could not tolerate too much work load. There was no dryness and bitterness in his mouth. He did not suffer from headache or dizziness. His heart rate was normal. Bowel movement and urination were normal. His tongue was slightly yellowish.  Professor Yang thought, according to the symptoms of the tongue and pulse, the patient¡¯s condition was caused by the deficiency of heart, spleen and qi as well as stagnation of qi transforming into fire. Therefore, the treatment should be freeing the liver and removing stagnation of qi as well as invigorating the spleen and nourishing the kidneys.

Date: Jan. 20, 2011                                        Time: 10:00 am

The patient said his spirit and sleep were good. His appetite was normal. His pulse was floating and slightly weak. His tongue was slightly red with thin coating. There was no bitterness or dryness in his mouth. His bowel movement and urination were normal.

Date: Jan. 23, 2011                                        Time: 10:00 am

The patient said his spirit and sleep were good. His appetite was normal. There was no bitterness or dryness in his mouth. His bowel movement and urination were normal. His tongue was slightly red with white coating. Continued the previous formula.

Date: Jan. 31, 2011                                        Time: 10:00 am

All conditions of the patient were normal. His pulse was normal. His tongue was slightly red with thin and white coating.

Date: Feb. 9, 2011                                        Time: 11:00 am

The patient was of high spirit these days. Sleep and appetite were very good. His pulse was normal. His tongue was slightly red with thin and white coating.

Date: Feb. 25, 2011                                        Time: 10:00 am