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Record of Hospitalization



Name: Mr. A Sex: male

Age: 43 Profession: computer program designer

Nationality: Saudi Arabia

Date of hospitalization:June 15, 2006

Marital Status: married



Major complaints:

The patient always has the symptoms of polyphagia, polydipsia, polyuria and thirst for three years. He also suffers back pains,and couldn’t stretch freely. He took an examination at the local hospital and found that he had hyperglycemia and high blood fat. He turns to TCM treatment because of the side effect caused by westernmedicine. Pressing pains of the left kidney area. Impotence. Dry and itching skin.



History of present illness:

The bowel movement is normal. The pulse is fine and rapid. Whitish and greasytongue coating. He has no infectious disease history of tuberculosis, hepatitis and typhoid. No history of blood transfusion and no allergy to any medicine.



Physical Examination:

Normalgrowth of her body and common nutrition level. Clear consciousness and cooperative. No yellow stain of the skin sclera. No edema of the superficial lymph nodes. Normal growth of his head and five senseorgans. Symmetrical size of the pupillae. Sensitive to the light reflection. No hyperaemia in the throat. No edema of the tonsil and thyroid gland. Thoracic cage is symmetrical. Clear percussion sound.Normal breath sound in the lungs. he heart rate are 74 times per minute. Normal rhythm of the heart. The abdomen is flat and soft. No pressing pains and no rebound tenderness. Pressing pains of theleft kidney area. Normal intestinal gurgling sound. No malformation of spinal column and limbs.

Diagnosis of Chinese Medicine : wasting-thirst (exuberant heat of lung and stomach)

Diagnosis ofWestern Medicine: diabetes type Ⅱ and hyperlipaemia.

The treatment strategy: clearing away the stomach-heat, reduce fire, nourish yin and boost qi. We use herbal tea combined with acupuncture...
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