QQ instant messenger history:
Jan. 3, 2015
Patient XX: Doctor yuan, do you still provide online consultation and prescription now?
Yuan: Yes, the procedure is …..
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Assessment form:
Date: Jan. 3, 2015
Gender: Male
Age: 30
Tongue picture:
gram positive cocci infection patient 1st consultation
On Dec. 10, when I used public toilet my glans was stained by some water on it. In the afternoon of that day I began to have a fever. There were red spots on the glans and it felt dry and sensitive. Prostate prickling pain. Strong smells on the glans. Fever.
On Dec. 19 I went to hospital. The test shows great amount of gram positive cocci, others are all negative. I took cefaclor they prescribed for me for 9 days and it has some improvements. Now the symptoms remained are: lower back pain, red spots on glans, discomforts in urinary tract, I felt weak, the dryness of the glans had improved. Lymphadenectasis in inguinal region
Yuan: Prescription of Jan. 3: 赤芍 白芍 厚朴 鱼腥草 海金砂 蒲公英 苍术 土茯苓 怀牛膝 杜仲 木香 甘草 etc., 7 days.
Yuan: Please avoid irritating food (hot pepper, garlic) and stimulating food (mutton, beef, seafood, poultry and milk) and try avoid sex during the treatment.
Yuan: After taking the medicine, it’s a good phenomenon to have more urination and defecation (eliminating toxin and pathogen) and should keep taking the medicine.
Patient XX: OK. Thank you doctor yuan. I’ll first take 7 days. Now I have many business trips, is it OK to ask the pharmacy to decoct the herbs for me?
Yuan: Decocting by your self is of course better than by the pharmacy. But if condition doesn’t allow you may only ask the pharmacy to do it. You may decide it according to yourself. Come back to adjust the prescription after taking this 7 days’ medicine.
Patient XX: OK. Thanks a lot.
Jan. 9, 2015
Patient XX: Doctor, I’ve taken 4 days’ herb and feedbacks are: now the urination and defecation are really increased. There’re still red spots on the glans. I feel weak at the lower back. The glans became dry again. I have severe sore throat 2 days ago and now have very sticky phlegm. I felt foggy in my head and tired.
Jan. 10, 2015
Yuan: Please feed back together in the assessment form in the follow-up consultations after finishing all your medicine.
Patient XX: All right. OK.
Jan. 11, 2015
Patient XX: By the way, Doctor yuan, I felt after the meridians are unblocked, I also have borborygmus and diarrhea and the overall feeling is very good. The medicine is very correct.
Yuan: Yes. Once being unlocked, the pathogen and toxin are eliminated, the disease will recover spontaneously.
Yuan: Prescription of Jan. 11: 黄芪 独活 炒白术 泽泻 猪苓 山萸肉 厚朴 鱼腥草 苍术 土茯苓 怀牛膝 杜仲 木香 甘草 etc., 7 days.
Patient XX: Doctor yuan, can I eat ducks?
Yuan: It’s better avoid any meat.
Jan. 28, 2015
Patient XX: Doctor yuan, after taking 7 days’ herb of last prescription, I added several days’ more. Then I stopped the medicine and investigated for a period of time. And found it’s totally gone now. Thank you very much doctor yuan.
Yuan: you are welcome.
Yuan: Pay attention to avoid stimulating food for some time to stabilize and consolidate your condition.
Chinese Herbal Medicine Treatment Cases 