Patient:Zhang X, Male, born in May, 2003
First diagnosed on 19 December, 2012
Chief complaint: Repeated outbreaks of epilepsies for 5 years
History of Present Illness: The patient fell and injured his head, and was unable to move one of his upper arms when he was 2 years old. When he was five years old, he was struck by epilepsies for the first time and no sign of high fever before that. The symptoms could be described as violent body-shaking, neck rigidity, eyes staring upward and salivation. The symptoms automatically relieved seven or eight minutes later. After that, the patient received treatment (drug-use was unclear) in Shanghai Children’s Hospital without any improvement, and the epilepsies later happened many times. The brain electrical activity mapping obtained from People’s Hospital of Yugan County in Nov. 26, 2012 turned out to be abnormal. The patient sighed frequently and responded slowly with dull eyes in diagnosis. Moreover, the patient hadcar-sick and tended to vomit and drool. The build of the patient is plump, but the complexion was pale and fingers got warm voluntarily.
Pulse Taking: The patient had weak and slippery pulse. The soft pulse in the right hand was large, the Cun Pluse was floating and the Chi Pulse was forceless and deep. The pulse of left hand was slightly weak with forceless and deep Cun Pulse, while Guan and Chi Pulse were taut.
Tongue Diagnosis:the tongue was slightly pale with fat moss and full-white thick coating.
Western Medicine Diagnosis:epilepsies.
Chinese Medicine Diagnosis:epilepsies.
Syndromes conclusion:The Qi was deficient and stagnated, and the phlegm contained dampness and wind.
Prescription: smashed semen coicis 12g, smashed apricot kerne l6g, folia perillae acutae 6g, codonopsis pilosula 12g, Scutellaria baicalensis 9g, arisaema cum bile 9g, bighead atractylodes rhizome 12g, poria cocos 12g, acorus gramineus6g, gastrodia elata 9g, smashed rhizoma pinellinae praeparata 8g, dried orange peel 9g, bamboo juice 20ml, prepared radix glycyrrhizae 9g (6 doses, boiled and take twice after meals).
Nursing Requirements and Prohibitions:Eat bland food, and avoid milk.
Observation after Diagnosis:observing sweating: when the patient sweated in the upper body, it was necessary to touch from the shank to the thigh to check the amount of the sweat. Was the urine muddy? Did the patient sweat in sleeping?
After Fourteenth Diagnosis: Up until June 30, 2014, the patient suffered no occurrence of Epilepsies, and the dullness of eyes changed for the better. He spoken much more fluently, responded quickly, answered well, but looked slightly sideways.
Chinese Medicine Syndrome Conclusion:
The patient showed qi-deficency of spleen and lung and stagnation of wet phlem. Pericardium was blocked suddenly by evil wind ,dampness and Phlegm. There was evil wind remaining in the exterior of Taiyin meradians. It was better to for the patient to take chinese medicine.
Prescription of Chinese Medicine: rhizoma pinellinae praeparata 9g, rhizoma atractylodis macrocephalae 12g, gastrodin9g, radix curcumae 8g, acorus gramineus 6g, 8g, white ginseng 5g, honey-fried radix astragali 10g, root of red-rooted salvia 12g, wolfberry fruit 9g, processed rhizoma arisaematis 5g, coix lacryma jobi 12g, red flower 8g, angelica archangelica 6g, radix paeoniae rubra (wine fried) 6g, dipsacus root 9g, semen cuscutae 9g, ground beeltle5g (12 doses, smashed, sifted over 100 heads and made into water pills, twice a day and 8g once ).