Brief Summary: Abbas, from Sudan, has suffered from inhibited urination for six years, accompanied by numbness of the lower limbs. After eighteen-day treatment in our hospital, he has achieved obvious improvement.

Record of Hospitalization

Name: Abbas                                                 Sex: Male

Age: 62                                                          Profession:  Doctor

Nationality: Sudan                                         Marital Status: Married

Onset Season: Spring                                    Date of Admission: May 25, 2007  

Complainer: The patient himself                      Reliability: Reliable

Chief Complaint: The patient has suffered from inhibited urination for six years, accompanied by numbness of the lower limbs. 

Present Illness: Six years ago, the patient had inhibited urination with strangury, and felt abdominal distention with some discomfort. Then he went to a local hospital (unknown) for treatment. After the examination of B-ultrasonic, he was diagnosed as “hyperplasia of enlargement”, and prescribed with corresponding medicine (unknown). His disease conditions got some improvement. After that, his disease attacked repeatedly. The patient still suffered from numbness and pains of the lower limbs, sometimes involving in his toes. The hospital diagnosed it as “sciatica sciatic neuralgia”, and treated with physiotherapy. Then he got some improvement, but attacked sometimes. To get traditional Chinese medicine treatment, he came to our hospital for his MS treatment on May 25, 2007, together with his wife. Since he got the disease, his spirit and appetite were both normal, and his sleep was good. His bowel movement was normal. He had inhibited urination.

Disease History: With healthy body over the past. No history of typhoid, tuberculosis, hepatitis, malaria or other infectious diseases. No history of injuries or surgery. No history of medicine or food allergy. No history of blood transfusion. No history of preventive vaccination provided.

Personal History: He was born in Sudan. No contact history of schistosomiasis. No addiction to alcohol, smoking or special food. He was mild-tempered and open-minded.

Marital History: He got married at the age of 23. He has two sons. His wife and his sons are all healthy.

Family History: No family history of special disease.

Physical Examination:

T 36.5℃，P 78 beats/minute, R 20 times/minute, BP 140/80 mmHg.

He grew normally with common nourishment. His mind was clear. He had an expression of chronic illness and languidness. His body was in a positive posture and he was cooperative in examination. His skin was moist. No jaundice in the sclera. No superficial lymph-node enlargement. Bilateral pupils were 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 was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs of heart on auscultation. Abdomen was flat and soft without tenderness or rebounding tenderness. The liver and spleen were not palpable. No percussion pains on renal region. Bowel sound was normal. No Spinal and pelvic deformity or tenderness. No deformity or inflexibility of the upper limbs. The patient felt numbness and pains of the lower limbs, sometimes involving in his toes. His left and right legs can raise 30 degrees (+). He felt inhibited urination with strangury. Other physiological reflex has not been elicited. His tongue was red with thin and white tongue coating. The pulse was deep and thready.

Diagnostic examination: Not provided.

First Diagnosis: 

TCM diagnosis: Taxation Strangury

Symptom identification: Deficiency of the spleen and kidneys, accompanied with damp-heat brewing.

Western medicine diagnosis: 1. Hyperplasia of enlargement

                      2. L₄-S₁ lumbar disc protrusion

First Medical Record

14:30 p.m. May 25, 2007

Abbas, a 62-year-old male, has suffered from inhibited urination for six years, accompanied by numbness of the lower limbs. He arrived in Huaihua Red Cross Hospital for further treatment at 14:30 p.m. on May 25, 2007.

Essentials for Diagnosis:

1. The patient has suffered from inhibited urination for six years, accompanied by numbness of the lower limbs. 

2. Six years ago, the patient had inhibited urination with strangury, and felt abdominal distention and discomfort. Then he went to a local hospital (unknown) for treatment. After the examination of B-ultrasonic, he was diagnosed as “hyperplasia of enlargement”, and prescribed with correspondent medicine (unknown). His disease conditions got some improvement. After that, his disease attacked repeatedly. The patient still suffered from numbness and pains of the lower limbs, sometimes involving in his toes. The hospital diagnosed it as “sciatica sciatic neuralgia”, and treated with physiotherapy. Then he got some improvement, but attacked sometimes. To get traditional Chinese medicine treatment, he came to our hospital for his MS treatment on May 25, 2007, together with his wife. Since he got the disease, his spirit and appetite were both normal. His sleep was good. His bowel movement was normal. He had inhibited urination.

3. T 36.3℃，P 78 beats/minute, R 20 times/minute, BP 140/80 mmHg, K 67 kg.

4. He grew normally with common nourishment. His mind was clear. He had an expression of chronic illness and languidness. His body was in a positive posture and he was cooperative in examination.

5. When the patient discharged urine, he felt inhibited urination with strangury, accompanied by numbness and pains of the lower limbs, and sometimes involved in his toes. His left and right legs could raise 30 degrees (+). The brinell levy was normal.

6. No thoracic deformity. Chest percussion noted resonance. Sound of breath was bilaterally clear on auscultation. No pleural friction rubs.

7. Diagnostic examination: Not provided.

Diagnostic Basis:

TCM: The patient has suffered from inhibited urination for six years, accompanied by numbness of the lower limbs. There was damp-heat brewing in the lower burner and inhibited qi transformation of bladder. As his disease attacked repeatedly, his right qi was damaged gradually, even damage to the spleen and kidneys. Therefore, he suffered from weak wilting lumbus and knees, fatigue spirit and lack of strength. His symptoms were sometimes serious, and sometimes mild. As deficiency of kidneys with dampness evil and heat evil, he suffered from inhibited urination with strangury. With rough pains continually, his constitution was weak after long-term illness. His tongue was light with thin tongue coating. His pulse was thready and weak.

Western Medicine: The patient has suffered from inhibited urination for six years, accompanied by numbness of the lower limbs. When he discharged urine, he felt inhibited urination with strangury, accompanied by numbness and pains of the lower limbs, sometimes involving in his toes.

Diagnostic Differentiation: 

TCM: Taxation Strangury should be differentiated from dribbling urinary block. Dribbling urinary block is characterized as difficulty in discharging urine with small quality of urine, even along with dropping or no urine symptoms. The symptoms of small quality of urine and difficulty in discharging urine are similar to Taxation Strangury. Taxation Strangury is characterized as frequent urine with pains, smaller quality of urine than normal. When it becomes serious, his urination will occlude. There will be no urine to discharge.   

Western Medicine: Taxation Strangury should be differentiated from chronic pyelonephritis, which is with secret course of disease. A small number of people are intermittently attacked by symptoms of pyelonephritis. However, symptoms that are more common are these of lower urinary tract infection, such as intermittent bacteruria without any symptoms, and intermittently frequent and urgent urination. It has intermittent low-grade fever.  

First Diagnosis

TCM diagnosis: Taxation Strangury

Symptom identification: Deficiency of the spleen and kidneys, accompanied with damp-heat brewing.

Western medicine diagnosis: 1. Hyperplasia of enlargement

                       2. L₄-S₁ lumbar disc protrusion

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Regular diet.

4. Herbal tea (to supplement the kidneys and invigorate the lumbus, quicken the blood and transform stasis, soothe the channels and quicken the network channels): one dosage a day and drink twice.

Prescription: Varied Decoction of the Kidneys-Supplementing Stasis-Quickening.

Main herbs used in the herbal tea: shudi (cooked rehmannia root), danggui (tangkuei), sangjisheng (mistletoe), etc.

5. Acupuncture and massage: once a day.

6. Have more medical examinations if necessary.

Date: May 26, 2007                            Time: 9:00 a.m.

The patient complained to Dr. Yan about suffering from inhibited urination with strangury, accompanied by numbness and pains of the lower limbs. The examination of ECG was normal. The examination of B-ultrasonic showed hyperplasia of enlargement; six programs of hepatitis B were normal; the functions of his liver and kidneys were normal, with normal blood sugar and blood fat. Rheumatoid factor was (+). Both of his ESR and anti-“O” were normal.

Examination: T 36.3℃，P 78 beats/minute, R 20 times/minute, BP 140/80 mmHg.

His heart and lungs was normal. His abdomen was soft and flat.

Dr. Yan’s analysis:

1. The patient has suffered from inhibited urination for six years, accompanied by numbness of the lower limbs. 

2. When the patient discharged urine, he felt inhibited urination with strangury, accompanied by numbness and pains of the lower limbs, and sometimes involved in his toes. His left and right legs could raise 30 degrees (+).

3. National examination: 1. Hyperplasia of enlargement

                     2. Sciatica sciatic neuralgia

According to the above information, TCM considered diagnosing as Lin-syndrome (Taxation Strangury). Dr. Yan’s analyzed it was deficiency of the spleen and kidneys, accompanied with damp-heat brewing.

Principle of TCM treatment: Supplementing the kidneys and invigorating the lumbus, quickening the blood and transforming stasis, soothing the channels and quickening the network channels. Herbal tea prescribed for five days including shudi (cooked rehmannia root), danggui (tangkuei), sangjisheng (mistletoe), etc. One dosage a day and drink twice.

Doctor’s requirement is to take five dosages of the herbal tea of the same prescription. Acupuncture and massage for once a day. The patient will have more medical examinations if necessary.

Date: May 27, 2007                           Time: 9:00 a.m.

The patient did not complain about any other special discomfort and told the doctor that he still suffered from inhibited urination with strangury, accompanied by numbness and pains of the lower limbs. His heart and lungs was normal. His abdomen was soft and flat. His spirit and appetite were both normal, and his sleep was good. His bowel movement was normal. The examination of his lower limbs was the same as before. His tongue was light red with thin and white tongue coating. His pulse was deep and thready. Doctor’s requirement is to take herbal tea of the same prescription.

Date: May 28, 2007                           Time: 9:00 a.m.

Today the patient did not complain about any other special discomfort and told the doctor that his inhibited urination with strangury and numbness and pains of the lower limbs all got some improvement. His heart and lungs were normal, and his abdomen was soft and flat. His spirit and appetite were both normal, and his sleep was good. His bowel movement was normal. The examination of his lower limbs was the same as before. His tongue was light red with thin and white tongue coating. His pulse was deep and thready. Doctor’s requirement is to take herbal tea of the same prescription.

Date: June 2, 2007                          Time: 9:00 a.m.

Today the patient did not complain about any other special discomfort. Meanwhile he told the doctor that his inhibited urination with strangury and numbness and pains of the lower limbs all got some improvement. His heart and lungs were normal, and his abdomen was soft and flat. His spirit and appetite were both normal, and his sleep was good. His bowel movement was normal. The examination of his lower limbs was the same as before. His tongue was light red with thin and white tongue coating. His pulse was deep and thready. Doctor’s requirement is to take five dosages of the herbal tea of the same prescription. One dosage a day and drink twice.

Date: June 7, 2007                          Time: 9:00 a.m.

Today the patient did not complain about any other special discomfort. Meanwhile he told the doctor that his inhibited urination with strangury and numbness and pains of the lower limbs all achieved obvious improvement. His heart and lungs were normal, and his abdomen was soft and flat. His spirit and appetite were both normal, and his sleep was good. His bowel movement was normal. The examination of his lower limbs was the same as before. His tongue was light red with thin and white tongue coating. His pulse was deep and thready. Doctor’s requirement is to take the herbal tea of the same prescription.

Date: June 12, 2007                          Time: 9:00 a.m.

Today the patient did not complain about any other special discomfort. His disease condition was stable.

Date: June 14, 2007                          Time: 9:00 a.m.