明大夫主治来自东京的英国先生Slaughter皮肤干燥瘙痒综合症之住院英文病历
Record of
Hospitalization
Name:
Jonathan Slaughter Gender: Male
Age:
38 Marital State:
Married
Profession: Ballet Dancer Address of Birth: Worthing, UK
Nationality:
British Current Address: see below*
Date of Hospitalization: August 1,
2004. Record Date: August 1, 2004
Major complaint: Dry skin for 38 years,
severe itching, 24 hours scratching everyday, multiple skin
ulcers, past treatments no help.
Disease history: Jonathan complained that
when he was born, mother found cuts on his arms and dry
skin. So his mother tried to use western cortisone and
steroid external use cream for him to relieve the dryness of
the skin. When he was 18 years old, he went to Central
Ballet School in London and studied Ballet techniques for
two years. During this period, he still was using the cream,
pills and injections.
*Chibashi
Chuouku
Aoba Cho
1269
Aoba Cho No
Mori
Koen Dori
7-401
Japan
When he was 25 years old, he tried to
stop steroid, then he felt pretty much worse. The symptoms
are fatigue, sorness of the joints, joint stiffness, thick
skin, even could not turn his neck.. When he was 32 years
old, he went to Tokyo, Japan to teach the local people the
techniques of Ballet. He used quite a lot herbal treatment
in Japan for two years, yet no obvious improvement was
found; he was given fire-purging Chinese herbal medications
and this even made him feel cold in hot summer.
Currently, the major complaint is dry
sense of the skin which feels like hard paper, fatigue,
itching very severely, and has to scratch all the time,
falling off of the skin flakes at most parts of the body
skin. The two hands, two feet and the back part of the knees
have obvious ulcers, especially the swelling of the two
feets and ankles is severe. Thirst and liking much water of
normal temperature, constipation often.
Five years ago, he felt irregular beats
of the heart. But right now, this feeling has disappeared.
Asthma lasted all the time till recent four years, during
which no onset of asthma was found. When asthma happened, it
is three or four times every week. He feel always blockaded
nose, nasal excretion is yellow.
Jonathan is allergic to horse, any other
animal with body hair, sometimes honey and alcohol. He also
said the right kidney is bigger than the left kidney, but no
nephritis or kidney stone or infection was found.
The total body check is carried out.
T37.1C, P 90 beats/per minute, BP 120/70 mmHg.
The left pulse is thready and
string-like, right pulse soggy. The tongue is enlarged,
moist and without tongue coating.
Diagnosis: Yin deficiency, fulminant
fire, external wind disturbing, blood dryness, the skin
fails to be nourished.
Treatment strategy: Moistening yin,
clearing heat, expelling wind, stopping itching, enriching
blood.
So the formula for oral use is as
follows. Take 200 milliliters in the morning 10:00 AM, and
another 200 milliliters in the afternoon 4:00 PM.
glehnia root 12g ophiopogon
tuber 12g Solomon’s
seal root 12g
scrophularia
root 12g honeysuckle
15g wild
chrysanthemum flower 15g
xanthium
10g cnidium seed
10gschizonepata
1 0g
ledebouriella 10g
ligusticum
root 12g peach kernel
12g tangkuei
root 10g
The second formula is for external use
for bathing, soaking, washing the skin for twenty minutes in
11:00 AM and 5:00 PM for another twenty minutes.
schizonepata
30g
ledebouriella 30g licorice
root 50g
honeysuckle
80g xanthium 50g stemona
50g salvia root
30g
cnidium seed
50g glehnia
root40g ophiopogon
tuber 40g
Solomon’s
seal root 40g scrophularia
root 40g rhubarb
20g
Prescribed by Dr. Ming 2004.8.1
August 2, Jonathan said he could get used
to the internal use herbal tea and external use soup.
Washing and soaking the skin for 15 minutes. It is too early
to say if there is good change. But it seems to him that he
feel the skin on the arms is less itching. The ulcer on the
feet is less itching and would like to have some cream to
moisten the local skin.
Dr. Ming, 2004, 8, 2.
August 3, Jonathan said the taste of the
herbal tea is acceptable, not too much bitter and not too
much cold in nature. Yesterday afternoon after coming back
from exposing to strong sunlight for two hours, itching is
even stronger, and the feet feel hurting stronger. But if
exposing too strong sunlight in the past, he has to scratch
strongly, but this time he did not need to scratch. This
morning he feels the skin seems to be a little bit moist. I
checked the total body skin, dry indication and flakes could
be found. It is obvious that the ulcers at the back of the
two knees are disappearing. The ulcers of the feet are still
obvious. So the internal use herbal formula is as follows:
glehnia root
12g ophiopogon
tuber 12g Solomon’s
seal root 12g
scrophularia
root 12g trichosanthes root 10g honeysuckle
15g
wild
chrysanthemum flower 15g xanthium
10g cnidium seed
10g cicada
molting 10g
schizonepata
1 0g ledebouriella 10g tangkuei
root 10g anemarrhena
root 10g
arctium seed
10g
Two dosages: 200 ml in the morning,
another 200ml in the afternoon.
The external use formula is as follows:
schizonepata
30g
ledebouriella 30g licorice
root 50g honeysuckle
80g
xanthium 50g stemona
50g cnidium seed
50g glehnia
root40g
ophiopogon
tuber 40g Solomon’s
seal root 40gscrophularia
root 40g
trichosanthes root 40g
phellodendron bark 40g
anemarrhena
root 40g
rhubarb
20g cicada
molting 40g flavescent
sophora root 40g
arctium seed
40g
Two dosages: washing externally once in
the morning 11:00AM, 5:00PM.
Offer external use ointment, Meibao Moist
Scalds Ointment to use external on the feet to moisten the
local skin, twice a day.
Dr. Ming, 2004.8.3
August 4, Slaughter said yesterday from
the morning till 9:30 PM, rare feel itching sense. In the
past, the whole daytime and night are of severe itching. But
after 9:30, he feels itching and has to scratch, sleep is
relatively relaxed. This morning the itching of the face is
relatively more compared to other part of the total body
skin. I found that the ulcers of the two feet are getting
better, swelling is reduced 20%.
Dr. Ming, 2004.8.4
August 5, Slaughter is feeling that
itching degree is reduced 50% percent in the daytime and 90%
percent reduced at night. I found that the skin is becoming
little bit moist and the ulcers on the feet are continuing
to heal.
Dr. Ming, 2004.8.5
August 6, the skin itching degree is
continuing to decrease. The feet itching is reduced
obviously. Now the upper part of the body including the
face, neck, chest, upper back is still dry and itching. More
skin flakes come down. Advice the patient to use Meibao
Moist Scalds Ointment on these severe parts of skin for two
to three days to see the result. I tried to touch the skin;
the skin feels like hard paper. So the internal use formula
is trying to strengthen the effect of moistening the skin.
glehnia
root15g ophiopogon
tuber 15g Solomon’s
seal root 15g
scrophularia
root 15g asparagus
tuber 15g trichosanthes root 10g
honeysuckle
15g wild
chrysanthemum flower 15g xanthium
10g cnidium seed
10g
cicada
molting 10g schizonepata
1 0g edebouriella 10g
tangkuei
root 10g anemarrhena
root 10g arctium seed
10g
The external use formula also strengthens
the effect to moistening the skin.
schizonepata
30g licorice
root 100g honeysuckle
80g xanthium 50gstemona
50g cnidium seed
50g glehnia
root60g ophiopogon
tuber 60g Solomon’s
seal root 60g scrophularia
root 60g trichosanthes root 60g
asparagus
tuber 60g phellodendron bark 40g
anemarrhena
root 40g rhubarb
20g cicada
molting 40g
flavescent
sophora root 40g arctium seed
40g
In
addition offer another tube of Meibao Moist Scalds Ointment,
use on the upper part of the body skin.
Dr. Ming,
2004.8.6
August 7, the general condition is
continuing to be improved. The crispy and hard skin which
touches like hard paper is becoming moist. The scratching is
much less, and itching degree reduced obviously. Sleep is
calm, appetite good, spirit good. Jonathan used cream on the
top part of the body skin twice yesterday. The ulcers on the
feet are being improved.
Dr. Ming,
2004.8.7
August 8, the skin is becoming obviously
moist. Only the skin of the neck is still dry apparently.
The itching is still from time to time, but much relieved.
The spirit and sleep are quite good. Yesterday, some friends
in Huaihua and our hospital accompanied Jonathan to our
local park. Since the weather is too much hot, so when
coming back after 5 hours sightseeing, the itching worsens a
little bit, but compared to before, the itching is much
slighter.
So almost continue the same treatment
strategy, put some blood quickening herbs to improve the
slight swelling of the feet.
So the oral use formula is as follows:
glehnia
root15g ophiopogon
tuber 15g Solomon’s
seal root 15g
scrophularia
root 15g asparagus
tuber 15g
trichosanthes root15g
honeysuckle
15g wild
chrysanthemum flower 15g xanthium
10g cnidium seed
10g
cicada
molting 10g schizonepata
1 0g
ledebouriella 10g tangkuei
root 10g
anemarrhena
root 10g arctium seed
10g carthamus
flower 10g
The external
soaking formula is
schizonepata
30g icorice
root 100g honeysuckle
80g xanthium 50g
stemona
50g cnidium seed
50g glehnia
root60g ophiopogon
tuber 60g
Solomon’s
seal root 60g scrophularia
root 60g trichosanthes root 60g
asparagus
tuber 60g phellodendron bark 40g
anemarrhena
root 40g
rhubarb
20g cicada
molting 40g flavescent
sophora root 40g arctium
seed40g
tangkuei
root 40gcarthamus
flower 40g peach kernel
40g
August 9, the skin continues to become
moist. The feet itching are still there sometimes. The
itching at the upper part of the body is reduced greatly.
Dr. Ming,
2004.8.9
August 10, all the conditions continue to
improve. The skin is becoming moist and itching is reduced
greatly. Now the major task is to promote the recovery of
the feet swelling. So strengthen the blood quickening to
reduce the swelling of the feet.
The internal use formula two dosages as
below:
glehnia
root15g ophiopogon
tuber 15g Solomon’s
seal root 15g
scrophularia
root 15g asparagus
tuber 15gtrichosanthes root15g
honeysuckle
15g wild
chrysanthemum flower 15g xanthium
10g cnidium seed
10g
cicada
molting 10garctium seed
10g tangkuei
root 10g igusticum
root 10g
peach kernel
10g carthamus
flower 10g anemarrhena
root 10g sparganum
8g
zedoary 8g
The
external use formula is changed to the following:
licorice
root 100g honeysuckle
80g xanthium
50g temona
50g
cnidium seed
50g glehnia
root60g ophiopogon
tuber 60g Solomon’s
seal root 60g
scrophularia
root 60g trichosanthes root 60g
asparagus
tuber 60g
phellodendron bark 40g
anemarrhena
root 40g rhubarb
20g cicada
molting 40g
flavescent
sophora root 40g arctium seed
40g tangkuei
root 40g
carthamus
flower 40g peach kernel
40g sparganum
50g zedoary50g
Dr. Ming,
2004.8.10
August 11, the skin is becoming moist.
Yesterday massage half an hour of the legs. The feet
swelling are reduced very well. Even we could see the veins
now.
Dr. Ming,
2004.8.11
August 12, Jonathan said yesterday is the
best day that he feels so good, almost no itching. The mind
and body are totally relaxed. The swelling on the feet is
almost gone. Add cnidium 10g in the internal use formula.
Add cnidium 50g in the external use
formula.
Dr. Ming, 2004.8.12
August 13, the general condition is
steady. The skin is more moist. While yesterday feels very
itchy. This is due to the purpose we wish to promote the
final blood stasis on the feet.
Dr. Ming, 2004.8.13
August 14, tomorrow Jonathan will leave
Huaihua back for Tokyo by taking flight from Zhang Jiajie to
Shanghai. He said that he could find and feel 90% recovery,
this is the fastest recovery compared to any other
treatments in the past, and also he said that we could not
imagine the nightmare he experienced in his 38 years, so he
was very pleased. Continue to former formulas for one day.
In general, the TCM treatment is very
effective and safe, and good recovery has been obtained to
Jonathan's case. After 14 days treatment, the itching is
almost gone, the skin becomes moist, skin flakes very
little, the multiple ulcers are cured. The critical point
for this successful treatment is accurate Syndrome
Identification and different Treatment Determination.
Chinese medicine is curing the root of this disease. So hope
he could continue to use the formula in Japan for a period
to consolidate the result so that 100% recovery can be got.
Try to avoid spicy foods, alcohol, beer, fishy foods, relax
the mind, keep the happy emotion.
Dr. Ming
August 14,
2004.