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SARS: Clinical Trials on Treatment Using a Combination of Traditional Chinese Medicine and Western Medicine
(2004; 194 pages) View the PDF document
Table of Contents
View the documentAcknowledgements
View the documentIntroduction
View the documentReport of the International Expert Meeting to review and analyse clinical reports on combination treatment for SARS
View the documentReport 1: Clinical research on treatment of SARS with integrated Traditional Chinese medicine and Western Medicine
View the documentReport 2: Clinical efficacy of the treatment of SARS with integrated Traditional Chinese medicine and Western medicine: an analysis of 524 cases
View the documentReport 3: Manifestation of symptoms in patients with SARS and analysis of the curative effect of treatment with integrated Traditional Chinese medicine and Western medicine
View the documentReport 4: Clinical study on 103 inpatients undergoing therapy with integrated Traditional Chinese medicine and Western medicine
View the documentReport 5: Clinical observations of 11 patients with SARS treated with Traditional Chinese medicine
View the documentReport 6: Effects of applying integrated therapy with Traditional Chinese medicine and Western medicine on liver and kidney functions in patients with SARS
View the documentReport 7: Clinical research on 63 patients with SARS treated with integrated Traditional Chinese medicine and Western medicine
View the documentReport 8: Influence of integrated therapy with Traditional Chinese medicine and Western medicine on lymphocytes and T-lymphocyte subpopulations of patients with SARS
View the documentReport 9: Analysis of the clinical curative effects on patients with SARS of treatment with Traditional Chinese medicine and Western medicine
View the documentReport 10: Evaluation of clinical curative effects of Traditional Chinese medicine in treatment of patients convalescing from SARS
View the documentReport A: A herbal formula for the prevention of transmission of SARS during the SARS epidemic in Hong Kong Special Administrative Region - a prospective cohort study
View the documentReport B: Effects of Chinese medicine on patients convalescing from SARS in Hong Kong special administrative region - a prospective non-randomized controlled trial
View the documentReport C: Traditional Chinese medicine in the management of patients with SARS in Hong Kong Special Administrative Region - a case-control study of 24 patients
View the documentAnnex

Report 3: Manifestation of symptoms in patients with SARS and analysis of the curative effect of treatment with integrated Traditional Chinese medicine and Western medicine

Zhang Boli19, Liang Shuren20, Zhang Junping19 and Wang Hongwu19

19 Tianjin College of Traditional Chinese Medicine, Tianjin 300193
20 Tianjing Infectious Diseases Hospital, Tianjin 300073

Abstract. The objective was to examine the manifestation of Traditional Chinese medicine (TCM) symptomatology in patients with severe acute respiratory syndrome (SARS) and observe the curative effects of a therapeutic regimen integrating TCM and Western medicine. A questionnaire on TCM symptomatology was adopted for research on patients with SARS to obtain data during the early, middle and late stages of the illness. Therapy integrating TCM and Western medicine was evaluated by comparison with a group of patients treated with Western medicine alone. Manifestation of TCM symptomatology in SARS patients could be divided into three stages and five syndromes. The three stages were: the pyretogenic stage (1-7 days), cough and gasp stage (5-14 days) and convalescence stage (14-21 days and later). The five syndromes were as follows: invasion of pathogenic factor into the lung which usually occurs in the pyretogenic stage; retention of virus in the lung and impediment of the activities of the lung which mainly occur in the cough and gasp stage; deficiency of both qi and yin and stagnation of phlegm in the lung which occur during the convalescence stage. Observation of the curative effects indicated that both integrated treatment and treatment with Western medicine alone could improve oxygen saturation and there was no obvious difference between the two groups. Once oxygen saturation had been normalized, fluctuations were reduced by integrated treatment. The case fatality rate in the integrated treatment group was 20% (5/20), whereas that in the group treated with Western medicine was 30% (6/20), indicating that the integrated treatment had a tendency to reduce the case fatality rate from SARS. This research indicates that therapy with integrated TCM and Western medicine was superior to therapy with Western medicine alone in treating SARS.


Infectious atypical pneumonia, which is caused by a new kind of corona virus, has strong infectivity and can affect several internal organs. The World Heath Organization (WHO) has termed it severe acute respiratory syndrome (SARS) (1). Its clinical symptoms include constitutional symptoms (fever, hypodynamia, headache, muscle pain and aching joints) and respiratory symptoms (dry cough, chest distress and dyspnoea). Following the first imported case reported in Tianjin in April 2003, we conducted an investigation into the clinical symptomatology of SARS according to TCM, and studied the effects of intervention with integrated treatment in the designated SARS hospitals.

Objects and methods

Objects tested

Source of cases

The cases were some of the patients with confirmed SARS admitted to designated SARS hospitals in Tianjin from 19 April to 6 June 2003.

Diagnostic criteria

The diagnostic criteria used conformed to those set out in Clinical diagnosis criteria for infectious SARS and Diagnostic criteria for severe SARS cases promulgated by the Ministry of Health of the People's Republic of China. SARS was confirmed and diagnosed according to factors including the epidemiological history, fever, continuous increase of the peripheral leukocyte count, appearance of an infiltrative shadow in the lung and ineffectiveness of antibiotic treatment. In addition, diseases of the respiratory system having similar clinical manifestations, such as infection of the upper respiratory tract, influenza, and bacterial or fungal pneumonia were excluded.

Inclusion criteria

Patients who met the diagnostic criteria and agreed to participate in the studies were included. Those who received treatment with Western medicine alone were included in the Western-medicine-treated group, and those treated with integrated TCM and Western medicine were assigned to the integrated treatment group.

Exclusion criteria

Patients who did not meet the diagnostic criteria or who did not consent to participate in the study were excluded.

Study design


The investigation tool used was a questionnaire on SARS TCM clinical symptomatology (see Annex).

Clinical therapy

The two treatment groups were studied concurrently to observe the curative effects of the two therapeutic regimens (integrated treatment and Western medicine alone) on SARS.

Therapeutic regimens

Therapeutic regimen with Western medicine

Therapy with Western medicine followed the recommended therapeutic regimen for severe SARS promulgated by the Ministry of Health, People's Republic of China, on 3 May 2003. The principles of the therapeutic regimen are summarized as follows:

• Antiviral drug: ribavirin 0.4 g, every 12 hours for 7 days.

• Glucocorticoid: methylprednisolone 40-320 mg/day, increasing the dosage when necessary, and up to 1 g/day for a severe case. The dosage was gradually reduced and discontinued when the condition of the patient had improved or the shadow on the chest radiograph had been absorbed according to a predetermined extent. (All the SARS patients in the present study were treated with glucocorticoid.)

• Oxygen inhalation or assisted respiration: Oxygen inhalation through a nasal tube was provided to the patients immediately after they were admitted to hospital. Those patients whose oxygen saturation was lower than 93% were provided with oxygen inhalation through a face mask, with an oxygen flow of 5-10 l/min according to the severity of illness. Continuous positive airway pressure ventilation was given to 24 patients to promote oxygen supply.

Therapeutic regimens of traditional Chinese medicine

The TCM therapeutic regimen for SARS recommended by the State Administration of Traditional Chinese Medicine, People's Republic of China on 11 April 2003, concerning characteristics of SARS in Tianjin City, entitled Traditional medicine therapeutic technical regimen of SARS in Tianjing area (revision) was adopted (2). The course of disease was divided into three stages (pyretogenic stage, cough and gasp stage, and convalescent stage) and there were seven types of treatment. The herbal decoctions were prepared by the decoction department of the hospital, and administered twice per day. All herbs used in the decoctions conformed to the requirements specified in the Chinese pharmacopoeia (2000 Edition, Volume I) and the patent medicines used were prescription drugs available commercially and approved by the Chinese drug administration.

Duration of study period

The study period was from the date of admission to the end of therapy or death.

Observation indexes

Symptomatological study

The investigation comprised three parts: basic information (e.g. age and sex), symptoms and tongue pictures. The symptoms investigated were scored as follows according to how often they were observed: A, never; B, occasionally; C, sometimes; D, usually; E, always. The investigation was performed during the course of disease which was divided into three stages: the early stage, middle stage and the late stage.

Clinical examination

The clinical examination included:

1. General impression; and

2. Laboratory examination (including routine blood examinations, biochemical tests, oxygen saturation, blood gas monitoring for patients with severe illness) and chest radiographs.

Criteria for determining when SARS patients could be discharged from Hospital

The criteria used for determining whether patients were ready to be discharged from hospital followed the Reference standard for the discharge of cases of infectious SARS issued by the Ministry of Health, People's Republic of China.

Quality control standard

The proposed study protocol was tested in repeated demonstrations and pre-surveys. Training seminars were held for professionals and training in the standard recording of symptoms was provided to familiarize investigators with the contents of the questionnaire to enable them to fill them out correctly and completely. Training also included guidance on the procedure necessary to ensure that each questionnaire was completed in a single session and ensure legibility and consistency of faxed questionnaires. Original data were immediately checked and verified; questionnaires were coded; double data-entry was used; 10% of the data were randomly selected and checked.

Data management and statistical analysis

A database was established using Epi data 2.1 to handle data management. Data were entered twice and statistical analyses were made using SPSS 10.0 and SAS6.12 software which included the following:

Reliability test: Cronbach’s alpha coefficient was adopted. Effectiveness was assessed using a factor analysis method.

Inclusion of symptoms of SARS for analysis: Factorial analysis and cluster analysis methods were used.

The statistical analysis of symptomatological and clinical effect data was done by means of frequency analysis, independent t-testing and chi-squared testing.


General situation

Among the 76 patients with SARS participating in this study, there were 31 patients with normal SARS, 19 of whom were in the integrated treatment group and 12 in the group treated with Western medicine. Forty-five of the patients had severe SARS (25 of these were in the integrated treatment group and 20 were in the group treated with Western medicine). Twenty-nine patients were male and 47 were female (a sex ratio of 1:1.6). The oldest was 83 years old and the youngest 19 years old. The average age was 42.2 ± 14.3 years (median age 44 years). The comorbidities included coronary heart disease (2 cases), hypertension (1 case), arrhythmia (1 case), nephritic syndrome (1 case), acute aplastic anaemia (1 case) and ascites due to cirrhosis (1 case). The average time from onset to admission was 1.6 ± 0.3 days for all patients.

Pattern of clinical symptoms during the early stage of illness

The first symptom of all 76 patients in this study was fever with a body temperature of more than 38ºC accompanied by anxiety, hypodynamia, headache, aching joints and myalgia (Fig. 1).

Fig. 1. Frequency of clinical symptoms of 76 patients with severe acute respiratory syndrome

Research on symptomatology

Reliability evaluation

Reliability evaluation was carried out using Cronbach’s alpha coefficient: alpha = 0.8692.

Effectiveness evaluation (constructional effectiveness) (Table 1)

Table 1. Eigenvalues of the reduced correlation matrix: total = 35; average = 1

























































Six factors retained by the NFACTOR criterion.

Evolution of traditional Chinese medicine symptomatology

Through the evaluation of reliability and effectiveness of the investigations reported on SARS TCM symptoms, in combination with the results from cluster analysis and factor analysis, SARS TCM symptoms can be divided into three stages and five syndromes. The three stages are the pyretogenic stage (1-7 days), cough and gasp stage (5-14 days) and the convalescent stage (14-21 days and later). The five syndromes are: invasion of pathogenic factor into lung, retention of virus in lung, impediment of the activities of the lung, deficiency of both qi and yin and stagnation of pathogenic phlegm.

The characteristics of the three stages are as follows:

during the pyretogenic stage, toxin and heat;
during the cough and gasp stage, stagnation and turbidity; and
during the convalescent stage, weakened healthy-qi with stagnation of pathogenic phlegm.

The five syndromes usually occur as follows:

• invasion of pathogenic factor into lung usually occurs during the pyretogenic stage;

• retention of virus in the lung and impediment of the activities of the lung occur during the cough and gasp stage; and

• deficiency of both qi and yin and stagnation of pathogenic phlegm occur in the convalescent stage.

The patterns of symptoms are described below.

Invasion of pathogenic factor into lung syndrome: fever, fear, anxiety, hypodynamia, anorexia, headache, aching body, exhaustion in the limbs, insomnia, weakened tone, then dry cough with little sputum, shortness of breath, deep-red tongue with thick fur.

Retention of virus in lung syndrome: high fever, sweating without reducing heat (fever), chest distress, fatigue, shortness of breath, breathlessness; dizziness, feeling of heaviness, abdominal distension, tiredness, difficulty in falling asleep and possibly agitation, reddened tongue with yellowish and white fur.

Impediment of the activities of the lung syndrome: declining high fever or stable temperature, breathlessness, rapid breathing, dyspnoea, chest distress, hypodynamia, anxiety, possibly mental weariness and incoherent speech, sweating and cold limbs, purple and dark lips, accompanied by weakened tone, tiredness, tongue with speckles.

Deficiency of both qi and yin syndrome: chest distress, dizziness, shortness of breath, hypodynamia, dysphoria with feverish sensation in chest, palms and soles, reddened complexion, slight thirst, mental weariness, distrustfulness, reddened or light red tongue, swelling of the tongue, pale fur.

Stagnation of pathogenic phlegm syndrome: breathlessness that becomes more serious when patient is moving, chest distress, hypodynamia, palpitations, joint aching, hair loss, anxiety, insomnia, deep-red tongue or speckled tongue, thin fur.

Influence of the two treatment regimens on oxygen saturation

Through the observation of oxygen saturation on the seventh, thirteenth and twenty-third days, in patients with normal SARS, integrated treatment and treatment with Western medicine were both found to improve oxygen saturation. There was no obvious difference between the two treatment groups. Similar results were obtained in patients with severe SARS; both treatment regimens improved oxygen saturation. The integrated treatment could obviously stabilize the fluctuation range of oxygen saturation that had been normalized, whereas this effect was less obvious with Western medicine alone.

Influence of the two types of treatment on case fatality rate

Of the 76 SARS patients studied, 65 (85.53%) recovered and were discharged from hospital. Of the 11 patients who died, five deaths were caused by SARS alone (6.58%); and six deaths resulted from complications of SARS (7.89%). None of the patients with normal SARS died; all of the 11 patients who died had severe SARS. Five of the patients who died were in the integrated treatment group, four of them had underlying diseases (two had coronary heart disease and one had arrythmia). The average age was 61.0 ± 15.0 years; the oldest was 83 and the youngest 48 years old. Of the six patients who died in the group treated with Western medicine, three had underlying diseases (one had ascites caused by cirrhosis, one had nephritic disease syndrome and one had aplastic anaemia and diabetes mellitus). The average age of patients in this group was 59.5 ± 10.7 years; the oldest was 72 and the youngest 45 years old.

On the basis of the above analysis, the case fatality rate in the integrated treatment group was 20%; whereas that in the group treated with Western medicine was 30%. No obvious difference between these two groups was seen. However, a tendency towards a reduction in the case fatality rate was noted in the integrated treatment group.


21 Note that parts of this discussion are aimed at explaining the pathogenesis from the perspective of Traditional Chinese medicine

SARS is a new disease that belongs to the category of epidemic febrile diseases according to its clinical symptoms and evolution. The cause of the disease is the invasion of virus through the mouth and nose. The main symptom of infection is fever, accompanied by hypodynamia, dry cough, dyspnoea and other symptoms. Noxious heat, stagnation and turbidity together with deficiency of healthy-qi are the three kinds of pathogenesis of SARS (3). This is a disease characterized by a sudden onset causing serious illness and rapid deterioration, with its nidus at the lung, but having a concurrent impact on other organs such as the liver, heart, spleen, stomach and kidneys.

The results of the analysis of the evolution of SARS TCM symptomatology and pathogenesis obtained in this study are generally in conformity with the theory of epidemic febrile diseases in TCM. “When invading upward, the pathogenic fever shall impair lung first”; this is the common characteristic of both SARS and of more common epidemic febrile diseases. The difference is that the nidus of SARS is in the lung whereas that of epidemic febrile diseases is not. SARS is extremely infective; the illness does not follow the normal pattern of diseases in wi, qi, yin and blood, with the pathogen lingering in the qi system and predominating in mid-jiao in most cases, and symptoms of qi are severe and advance quickly, those involving the blood system are scarcely seen. Also, manifestation of impairment of qi causing hypodynamia can usually be seen at the early stage of SARS whereas at the early stage of other epidemic febrile diseases, impairment of body fluid and draining of yin can be observed, manifestation of the impairment of qi can only be seen at the late stage.

The main pathogenesis of SARS is the retention of virus in the lung, stagnation of pathogenic phlegm, impediment of the activities of the lung and deficiency of both qi and yin (4). The pathogenic fever originates from the virus entering through the mouth and nose to invade the lung first. Lung governs qi and commands wei, the health qi and the pathogens compete in the lungs causing patients to experience fever with chills and aching of the body; retention of virus in the lung and impairment and decreasing function of lung, so high fever and sweating without removal of pathogens, dry cough and breathlessness are seen. Invasion of epidemic toxin into the lung causes impediment of the lung function, so patients may experience breathlessness, chest distress, gasping and coughing, and production of little or no sputum. If the lung heat transfers into the intestine, fu-qi will be obstructed and turbidity will not descend. Obstruction of qi causes abdominal distension, poor appetite, nausea and vomiting. Epidemic toxin can alter the state of mind, so that patients may feel panic-stricken, terrified and perplexed. If the body's resistance fails to overcome the pathogenic factors and the virus penetrates deeper, the patient will experience simultaneous disorders in qi and yin systems that are manifested as agitation, dizziness and incoherent speech. During the course of the disease, epidemic toxin consumes qi and damages yin, which leads to hypodynamia, weariness, disinclination to talk, thirst, spontaneous perspiration and other symptoms. The earlier the damage of qi and yin occurs, the more serious the prognosis will be.

Traditional Chinese medicine can be used to intervene in the pyretogenic, cough and gasp and convalescent stage. Comparative superiority to Western medicine alone was seen at all stages (eliminating pathogenic factors, strengthening body resistance and preventing pathogenic transformation). Through clinical observation, physicians can identify the pathogenesis and provide treatment appropriate to each of the stages of the disease. The key point of pathogenesis in the pyretogenic stage is toxin and heat; stagnancy and turbidity are the key points in the cough and gasp stage; and asthenia is the key point in the convalescent stage. Pathological manifestations were the first to occur in most patients followed by clinical symptoms; symptoms may overlap in these stages. Therefore, with an understanding of the evolution rule of the disease, curative drugs for prospective treatment can be used at the next stage (5).

It is not appropriate to use hormone treatment at the pyretogenic stage. During the aggravated cough and gasp stage (emission process), hormone should be administered at a sufficient dose; 40 mg/day may be adequate, but it is possible to raise the dose up to 80-320 mg/day. Reduction of use of hormone and termination of treatment should be conducted with caution. The principle for dose reduction should be based on the standard criteria as judged by stable condition of illness, commencement of absorption of inflammation in the lung and alleviation of clinical symptoms. The intention should be to reduce the dose by one third in 3-5 days. Traditional Chinese medicine should be adjusted accordingly during the whole course of dose reduction and termination of hormone treatment; intravenous drips can be terminated first and replaced by small doses administered orally, which can then be stopped gradually.

This research demonstrates that even when a complete and thorough knowledge of pathogenesis, pathological change and rule of evolution of SARS is not available, TCM, with its unique theoretical system, can “observe pulse syndromes to understand which pathogen invaded”. A reasonable TCM analysis of the etiology and pathogenesis of the disease can be made, and appropriate TCM treatment can be provided based on overall analysis of a patient's condition in order to stabilize oxygen saturation and reduce the abnormal fluctuation range. It can reduce the case fatality rate of severe cases. The results of this study therefore indicate that TCM has advantages in treatment of SARS.


This paper is dedicated to those medical professionals in Tianjin who lost their lives in the campaign against SARS, and we acknowledge our indebtedness to the State Administration of Traditional Chinese Medicine, Tianjin Science and Technology Commission and Tianjin Municipal Bureau of Health, for their assistance and support.


1. Peiris JSM et al. Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet, 2003, 361:9366-9374.

2. Tianjin SARS Treatment and Command Centre. Applying traditional Chinese medicine: technical regimens for treatment of SARS applying TCM therapeutics in Tianjin area. Tianjin Journal of Traditional Chinese Medicine, 2003, 20:108.

3. Wang Yongyan. Analysis on treatment of severe acute respiratory syndrome (SARS) based on its overall syndromes. Tianjin Journal of Traditional Chinese Medicine, 2003, 20:1-3.

4. Zhang Junping, Zhang Boli. Perception from treatment of SARS applying traditional Chinese medicine and therapeutics. Tianjin Journal of Traditional Chinese Medicine, 2003, 20:22-24.

5. Zhang Boli, Wang Xiaohui. Denomination, stages and pathogenesis of SARS. Tianjin Journal of Traditional Chinese Medicine, 2003, 20:12-14.

6. Zhang Boli, Zhang Junping. Approach to issues on SARS treatment applying therapeutics of integrated traditional Chinese medicine and western medicine. Tianjin Journal of Traditional Chinese Medicine, 2003, 20:5-7.

Questionnaire for severe acute respiratory syndrome - Traditional Chinese medicine symptomatology

Date of filling out the form:


Sex: male female


Inpatient No. or ward/bed No.:

Profession: student teacher medical professional manual labourer (except agricultural) government employee soldier or police officer farmer individual worker researcher business person unemployed retired other

Home address or work address:

Date of onset of disease:

Date of admission to hospital:

Date of discharge from hospital:
Diagnostic classification: normal case serious case
Number of days since onset (upon filling out the form):
Observation hospital:

TCM Diagnosis: early stage intermediate stage fastigium convalescent stage

Scoring instructions: A, never; B, occasionally; C, sometimes; D, often; E, always

1. Do you have fever? yes no

1.1 Quality of fever

1) Fever with aversion to cold 2) strong fever 3) intense fever in the afternoon
4) intense fever at night 5) hectic fever 6) low fever 7) recessive fever 8) cold shivers 9) dysphoria with feverish sensation in chest, palms and soles

2. Do you sweat? yes no

2.1 Quality of sweat

1) slight sweat 2) little sweat 3) excessive perspiration 4) cold sweat 5) morbid perspiration only over the head 6) excessive perspiration all over

3. Do you have the following symptoms? 1) cough 2) dry cough 3) expectoration

3.1 Quality of expectoration

1) expectoration with blood streaks 2) little sputum 3) copious sputum 4) rale in the throat 5) thick sputum hard to expectorate 6) yellow sputum
7) white sputum

4. Do you have the following symptoms?

1) chest stuffiness 2) shortness of breath 3) breathlessness 4) gasping 5) dyspnoea 6) great difficulty with breathing 7) palpitations

5. Do you have the following symptoms?

1) aching all over 2) headache 3) dizziness 4) head feels like it is tightly bound 5) tiredness and heaviness of limbs 6) heavy body 7) chest pain 8) sore throat 9) dry throat

6. Do you have the following symptoms?

1) mental weariness 2) hypodynamia 3) deficiency of qi 4) disinclination to speak 5) inclination to yawn 6) inclination to sleep 7) susceptibility to sighing 8) vexation

7. Do you suffer from insomnia? yes no

7.1 Characteristics of insomnia: 1) difficulty falling asleep 2) dreamful sleep 3) easily awakened 4) wake early 5) others

8. Do you have the following symptoms?

1) dry mouth 2) bitter taste 3) stickiness in the mouth 4) thirst 5) nausea 6) vomiting 7) constipation 8) loose stool 9) sticky stool 10) deep-coloured urine 11) poor appetite 12) normal appetite 13) abdominal distension 14) flatulence from bowels

8.1 Type of thirst:

1) slight thirst 2) fond of hot drinks 3) fond of cold drinks 4) thirsty but want no drinks 5) want to gargle but not swallow

9. Do you experience one or more of the following feelings?

1) terror 2) anxiety 3) irritability 4) panic 5) melancholy 6) sorrow 7) doubt 8) impetuosity 9) over-meditative

10. Have you any of the following symptoms? 1) involuntary movement 2) fondness for sleep 3) delirium 4) coma

11. Have you any of the following convulsion symptoms?

1) involuntary movement of fingers 2) convulsion of extremities 3) eyes looking upwards 4) clenched teeth 5) stiff neck 6) opisthotonos

12. Have you any of the following syncope symptoms? 1) chilly extremities 2) faintness

13. Mental condition: 1) normal 2) lassitude 3) fatigue 4) listless 5) over active

14. Voice: 1) normal 2) loud 3) low and timid (weak) 4) deep and vague 5) hoarse

15. Complexion:

1) red 2) flushed 3) flush on cheeks 4) yellow 5) sallow 6) pale 7) white 8) darkish

16. Facial lustre:

1) lustre 2) slight lustre 3) dim (no lustre)

17. Lip colour:

1) reddish 2) red 3) cyanotic

18. Tongue:

1) with teeth prints 2) swollen 3) thin 4) bristly 5) fissured
6) ecchymosis

19. Tongue tinge:

1) pale 2) pale red 3) red 4) deep red at the tongue tip 5) red at tongue edges 6) entire tongue deep red 7) dark red 8) crimson 9) purple (deep) 10) pale purple 11) cyanosis

20. Coating (A):

1) thin 2) slight coating 3) no coating 4) thick 5) greasy 6) curdy (deposit)

21. Coating (B):

1) even (normal) 2) complete coating 3) partial coating 4) lingua geographica 5) mirror-like tongue, smooth coating

22. Coating (C):

1) moist 2) slippery 3) little saliva 4) dry

23. Coating (D) - colour:

1) white 2) yellow 3) yellowish 4) yellow with white 5) grey (slightly grey) 6) carbon black 7) as mouldy paste 8) black (as soot)

24. Physical examination:

1) body temperature
2) respiration (times/min)
3) pulse (times/min)
4) blood pressure

25. Laboratory tests:

1) haemoglobin (g/dl)
2) white blood cell count
3) blood platelet count
4) PaO2 (kPa)
5) oxygen saturation (SpO2) (%)

26. Chest X-ray manifestation:

Signature of observer:……………………………………………………………………..


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