RECORD OF FIRST VISIT
| Date of First Visit: | Name: | |
| Date of Birth: 29 years | Gender: Male | |
| CHIEF COMPLAINTS : Diarrhea for 5 days | ||
| DESCRIPTIONS (4 diagnostic methods) | ||
A) Asking | ||
| He has drank a lot of alcohol during 5 days. That time he drinks alcohol more than eat food. Now he had gone to toilet 2~3 times a day. That time stool was loose stool with undigested food but not smelly. Slightly hot sensation in the anus. Usually he got diarrhea not only this time but also when he eat food too much. Lassitude. Eat food irregularly time but appetite is good. No fever and chill, Thirsty (He want to drink cold water), Yellow scanty urine and watery stool, No headache, enough sleep time and good quality sleep. | ||
| Past illness history : NAD | ||
| Life style: busy life due to study. Drink alcohol (Quarter bottle of wine a day) and smoke. | ||
| Family history : NAD | ||
| Menstruation, marital & obstetrical history : Single | ||
B) Inspection | ||
| General : Sallow complexion 7/10 Tongue: Pale tongue body with yellow sticky coating. | ||
C) Auscultation / Olfaction | ||
| Sound : NAD Odours : NAD | ||
D) Palpation | ||
| Pulse : Thready and rapid pulse Body areas : NAD | ||
CASE SUMMARY
DIAGNOSIS |
A) Diagnosis: Diarrhea |
| B) Syndrome Differentiation : Damp-Heat in Large intestine underlying Spleen qi deficiency |
C) Explanation |
| When the intestines and stomach are attacked by the damp heat, the transmitting and transformation function is disturbed, and diarrhea appears. If the heat stays in the intestines, there appear burning sensations in the anus. Yellow, sticky tongue coating and rapid pulse are the signs of excess of damp heat. In case of weakness of the spleen and stomach, the spleen qi fails to ascend and digestion is impaired; therefore, loose stool with undigested food appears. Persistent diarrhea further weakness the spleen and stomach, affecting the production of food essence and formation of qi and blood, and thus resulting in the sallow complexion and lassitude. Pale tongue and thread pulse are the signs of weakness of the spleen and stomach. |
TREATMENTS |
A) Treatment Principles Resolve damp expel heat, reinforce Spleen qi, Stop diarrhea |
B) Treatment Methods |
| 1. Needling |
| Prescription : |
| - Zhongwan, Zusanli, Yinlingquan, Neiting, Shangzuxu |
| Explanations : |
| - Zhongwan and Zusanli : invigorate the spleen yang, strengthen the function of transportation and transformation and stop diarrhea - Neiting and Yinlingquan: needled to eliminate damp heat from the LI. - Shangzuxu : for the diarrhea |
| 4. Life Style Advice |
| Reduce drink alcohol, eat food exactly time (3 times a day), do the exercise. |
WMS
In medicine, diarrhea, also spelled diarrhea (see spelling differences), is frequent loose or liquid bowel movements. Acute diarrhea is a common cause of death in developing countries and the second most common cause of infant deaths worldwide.
Diarrhea commonly results from gastroenteritis caused by viral infections, parasites or bacterial toxins.[1] In sanitary living conditions where there is ample food and a supply of clean water, an otherwise healthy patient usually recovers from viral infections in a few days. However, for ill or malnourished individuals diarrhea can lead to severe dehydration and can become life-threatening without treatment.[2]
Diarrhea can also be a symptom of more serious diseases, such as dysentery, cholera, or botulism, and can also be indicative of a chronic syndrome such as Crohn's disease or severe mushroom poisoning syndromes. Though appendicitis patients do not generally have violent diarrhea, it is a common symptom of a ruptured appendix. It is also an effect of severe radiation sickness.
Diarrhea can also be caused by dairy intake in those who are lactose intolerant.
Symptomatic treatment for diarrhea involves the patient consuming adequate amounts of water to replace that loss, preferably mixed with electrolytes to provide essential salts and some amount of nutrients. For many people, further treatment is unnecessary. The following types of diarrhea indicate medical supervision is required:
- Diarrhea in infants
- Moderate or severe diarrhea in young children;
- Diarrhea associated with blood
- Diarrhea that continues for more than two days;
- Diarrhea that is associated with more general illness such as non-cramping abdominal pain, fever, weight loss, etc;
- Diarrhea in travelers, since they are more likely to have exotic infections such as parasites;
- Diarrhea in food handlers, because of the potential to infect others;
- Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.
A severity score is used to aid diagnosis in children.[3]
TCM Etiology and Pathogenesis
The causative factors are complicated. But functional disturbance of the spleen and stomach is inevitably involved pathogenetically. The stomach dominates receiving food while the spleen dominates transportation and transformation. In case the spleen and stomach are diseased, the normal digestion and absorption of food is impaired, leading to mixing of food essence and wastes. When they descend through the large intestine, diarrhea occurs.
Diarrhea may be caused by the six exogenous pathogenic factors, among which mostly by cold, dampness and summer heat, the spleen is in preference to dryness but dislikes dampness, which usually causes diarrhea.
- Excessive intake of food
- Weakened function of the spleen and stomach due to irregular daily life or other factors.
- Deficiency of the Kidney
FOLLOW UP CONSULTATION
CASE CONCLUSION
The patient came to my clinic for treatment to diarrhea. So I focused on this symptom. Therefore, I was thinking First time I treat the patient used acu method for eliminate heat and damp and then second time I will give him the acu with moxa. But the patient doesn’t want to moxa. As a result, I can’t give him moxa. Thus, I finished treatment only use to needled. Next day I asked the patient’s condition he told me cured a lot.
So if a patient visit clinic same symptom I will give the same treatment.
