Name: Bala                                                                                                               Sex: Male

Age: 54                                                                                                                     Marital Status: Married

Nationality: Nigeria                                                                                                   Date of Admission: July 23, 2011

Date: July. 24, 2011                                      Time: 10:00 am

This 54-year-old gentleman had been suffering from wasting-thirst disease or diabetes for years, accompanied by impaired vision for 2 yeas. The patient was hospitalized in our hospital for TCM treatment on July 23, 2011.

Essential for Diagnosis:

1. The patient had been suffering from frequent drinking, eating and urination for 16 years, accompanied by impaired vision for 2 years.

2. The patient suffered from frequent drinking, eating and urination without any evident cause 16 years ago. After checked in his local hospital, his condition was diagnosed as diabetes. He was given some medicines to control his condition. Two years ago, he suffered from impaired vision, and the spectacles degree was increased from 300 to 600, while he still could not see objects clearly. At present, the patient felt dryness and bitterness in his mouth and liked warm drinking. Daily drinking volume was around 5L. He sometimes had dizziness and tinnitus. He controlled his own diet every day, and hunger sensation was not so evident. There were pains over his costal region of both sides. Sole of his feet was painful during walking and night. Urination volume was large with 5-6 times per day. The color of urine was slightly yellowish. He had night urinations about 2 times per night. His stool was dry and hard. Bowel movement was about once every two days. There were no abdominal pains or distension. He suffered decreased sexual function. He also suffered numb hands. He felt heat over his palms sometimes. And when this happened, he felt his heart beats were irregular. He felt drowsy and fatigued. He had profuse sweating. The patient slept about 12 hours every day. He did not suffer from weight loss. His blood sugar maintained at 13.3 mmol/L. In his family, his grandfather and two brothers all had diabetes.

3. T: 36.6¡ăC   R: 20 times/minute    P: 80 times/minute   BP: 120/70 mmHg

TCM: The patient suffered from frequent drinking, eating and urination for 16 years, which pertained to wasting-thirst disease. Dryness and bitterness in the mouth, preference to warm drinking, dry and hard stool, numb hands as well as heat in the palms were due to long duration of disease damaging the body fluids and yin deficiency generating internal heat. Drowsiness, fatigue and profuse sweating were due to qi vacuity. Therefore, his condition could be diagnosed as wasting-thirst disease, which was caused by deficiency of qi and yin.

Western Medicine: The patient suffered drinking, eating and urination for 16 years, accompanied by impaired vision for 2 years. In addition, he had such symptoms as dryness and bitterness in his mouth, preference to warm dinking, constipation, urination with large volume, night urination, and heat in the palms, numb hands, fatigue, profuse sweating and drowsiness. In the patient¡¯s family, there were people who had diabetes.

Diagnostic Differentiation:

TCM: The patient¡¯s condition should be differentiated with polydipsia, which is due to warm disease and pathogenic heat damaging body fluids. Polydipsia has the medical history of external contraction of warm evils and sees the transformation process of defense, qi, construction and blood (the four aspects). Besides, it shows no frequent eating and urination. Therefore, it was easy to differentiate them.

Western Medicine: His condition should be differentiated from uterine bleeding symptom. Both two have frequent urination and drinking, polydipsia, while uterine bleeding symptom does not show high blood sugar. So, it was easy to differentiate them.

First Diagnosis:

TCM: Wasting-thirst disease.

Symptom identification: the deficiency of qi and yin.

Western Medicine: Diabetics. 

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢̣ care.

3. Diet with lower sugar, fat and calorie.

4. Pathogenesis: the deficiency of qi and yin, spleen deficiency and dampness staying in the body. 

5. TCM strategy: to boost qi and nourish yin as well as to fortify the spleen and clear away heat.

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

7. Acupuncture and massage: once a day.

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

Dr. Ming paid a visit to the patient this morning. The patient complained of frequent drinking, eating and urination for 16 years as well as impaired eyesight for 2 years. He felt dryness and bitterness in his mouth, and he liked warm drinking. He sometimes suffered dizziness and tinnitus. There were pains over his costal region of both sides. Sole of his feet was painful during walking and night. His stool was dry and hard. His hands were numb. He felt heat over his palms sometimes. And when this happened, he felt his heart beats were irregular. He felt drowsy and fatigued. He had profuse sweating. Blood sugar kept at the 13.3 mmol/L. His family members had diabetics. His tongue was red with thin and yellowish tongue coating. His pulse was wiry and feeble. According the manifestations of his tongue and pulse, Dr. Ming thought in the view of TCM that the patient¡¯s condition should be wasting-thirst disease, which was due to the deficiency of qi and yin, spleen deficiency and dampness staying in the body. Therefore, the treatment should be to boost qi and nourish yin as well as to fortify the spleen and clear away heat. 

Date: July. 26, 2011                                         Time: 10:00 am

The patient said there were no pains over the sole of his feet. Dryness in the mouth and frequent urination were better. He had night urination once last night. Yesterday, the blood sugar after breakfast was 8.2 mmol/L, after lunch 11.2 mmol/L and supper 9.9 mmol/L. Report from today¡¯s lab check: Blood-R (-), vitc +, Glu +-, Blood-Glu 10.25 mmol/L. GCG: sinus rhythm.

Date: July. 27, 2011                                         Time: 10:00 am

The patient¡¯s condition was stable without any discomfort. Fasting blood-glucose was controlled at 9.0-11.0 mmol/L. Now he had stopped the check on fasting blood-glucose.

Date: Aug. 8, 2011                                         Time: 10:00 am

The patient¡¯s condition was stable without any discomfort. His tongue was red with thin and yellowish tongue coating. His pulse was slightly wiry. He suffered no night urination. His mouth was not dry any more. Huger sensation was not evident. There were no more pains over his body. The blood sugar kept at 9.0-10.5 mmol/L.

Date: Aug. 13, 2011                                         Time: 10:00 am