Brief Summary: On May 25, 2016, Mr. Yang Zuliang, from Zhongfang County near our hospital, who had been suffering from frequent micturition and odynuria for more than 4 years, being severe for one month. He was hospitalized in our hospital. His condition got great improvement after 20 days TCM treatment with the help of Acupuncture, Herbal tea and Tuina in our hospital.

　

                                                                           Record of Hospitalization

Name: Mr. Yang Zuliang                                                 Sex: Male

Age: 54                                                                          Marital Status: Married

Nationality: China                                                          Date of Admission: May 25, 2016

Companion: Alone

                                                                              First Medical Record

Date: May 25, 2016                                    Time: 9:30 a.m.

This 54-year-old man had been suffering from requent micturition and odynuria for more than 4 years, being severe for one month. The patient was hospitalized in our hospital for TCM treatment as a patient with prostatitis at 9:00 a.m. on May 25, 2016.

Essential for Diagnosis:

1. The patient complained 4 years ago there were frequent urination and odynuria  without any inducement. He took a check in the hospital, he was diagnosed with prostatitis. And he took the treatment in the local hospital, there is no obvious effect. He often had frequent and urgent urination. In this month, since the patient took the spicy food, the frequent urination became worse. He came to our hospital for TCM treatment.

2. When the patient came to our hospital, he suffered frequent urination and distending pain, when he drunk water the symptoms relieved, 14 to 16 times a day. He had a pain in his back, especially in the morning the pain became worse. He prefered to hot drink. He had dry mouth, dizziness with vomiting. He felt tired and weak. His appetite abd sleeping were poor. The bowel movement was three times a day.

3. T: 36.3＜C     R: 20 times/minute    P: 80 times/minute     BP: 130/70mmHg

4. The patient grew normally. He was alert and cooperative. He had chronic sick and edema facial and flushing complexion. There was no sign of yellow sclera or yellowish skin. There was no enlargement on the superficial lymph node of his whole body. Facial features were normal without masses and pressing pains. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. His ears were normal without secreta and pressing pain. His hearing was normal. His neck was soft without resistant. His windpipe appearance was good and in the center. There was no distention of jugular vein. There was no enlargement on his thyroid gland. His chest was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 80 times per minute. Heart rate was regular with no murmurs. We did not hear any pathologic sound. His abdomen was soft with no pressing pains, rebound tenderness and enclosed mass. There was no sign of deformity over his spine. There was pressing pain over his shoulders and lower back. No pathological neuropathic positive. His tongue was red with white and thin coating. His pulse was deep and retared.

Diagnostic Differentiation:

TCM:  Stranguria

Western Medicine diagnosis: 

1. Prostatitis

2. Kidney Stone

3. Lumbar Dic Herniation

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Å care.

3. Low salt and low fat diet, avoid wind-cold, regular daily life.

4. Completed the related examination, three routine inspection, the function of the kidneys and the liver, blood fat, blood sugar, anti-O, RF and IMX..

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

6. Acupuncture and massage: once a day

　

Date: May 26, 2016                                           Time: 10:00 a.m.

Dr. Shan, doctor-in-charge, paid a visit to the patient this morning. The patient complained 4 years ago there were frequent urination and odynuria  without any inducement, 14 to 16 times a day. He had a pain in his back, especially in the morning the pain became worse. He prefered to hot drink. He had dry mouth, dizziness with vomiting. He felt tired and weak. His appetite abd sleeping were poor. The bowel movement was three times a day. There was pressing pain over his shoulders and lower back. The activity of pitching was slightly limited. There was enlargement of prostate. The tongue body was red with whithe and thin coating. The pulse was deep and string-like. According to the above condition, Doctor Made the treatment strategy.

　

Date: May 26, 2016                                            Time: 12:00 a.m.

Test reports:

HB17.2 g/L ●, ESR 89 mm/h ●, HDL 0.81mmol/L◎, TP58g/L◎, Chlorine 94.2mmol/L◎

The result of the reports support the diagnosis.

　

Date: May 27, 2016                                            Time: 10:00 a.m.

The patient said the pain of lower back relieved. And the frequent urination improved,  compared with before, the urination was much more smooth and the frequency reduced. The spirit was better. Continued the formula.

　

Date: May 29, 2016                                            Time: 10:00 a.m.

The vital signs of the patient were stable. The patient said the symptoms obviously improved. Doctor adjusted the formula.

　

Date: June 2, 2016                                            Time: 10:00 a.m.

The patient said there was fullness with discomfort over his stomach. He still felt tired with dizziness. And his appetite was not good. While the pain over his lower back obviously improved. And the activity of pitching relieved, it was easier to move his body than before.

　

Date: June 6, 2016                                            Time: 10:00 a.m.

The patient said the fullness with discomfort over his stomach disappeared. After the meal the distending sensation over his stomach almost disappeared. And the dizziness improved. The urination was smooth now. The bowel movement was normal. Adjusted the formula.

　

Date: June 10, 2016                                            Time: 10:00 a.m.

The patient siad the fullness over his stomach disappeared. The spirit was good. Most of symptoms, frequent urination and odynuria obviously improved. And his appetite was normal.

　

Date: June 14, 2016                                            Time: 10:00 a.m.

The patient said the frequent urination and odynuria disappeared completely. He decided to leave the hospital today.