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Brief
Summary:
Ms. Fatma had been
suffering from lumbar pains and swelling eyelids, accompanied by
preteinuria for 6 years. Her conditions became severe in recent
2 years. She was hospitalized in our
hospital on October 21, 2011 for TCM treatment. She achieved
some improvement in her condition after one month TCM treatment
with the help of herbal tea, acupuncture, massage etc.
Record of
Hospitalization
Name:
Fatma Sex:
Female
Age:
50 Marital Status: Married
Nationality:
Omani Date of
Admission: Oct. 21, 2011
Companion:
Her Husband
First Medical Record
Date:
Oct. 22, 2011 Time:
10:00 am
This 50-year-old lady
had been suffering from lumbar pains and swelling eyelids,
accompanied by proteinuria for 6 years. Her conditions became
severe in recent 2 years. The patient was hospitalized in our
hospital for TCM treatment at 20:00 on Oct. 21, 2011.
Essential for Diagnosis:
1. The patient had been
suffering from lumbar pains and swelling eyelids, accompanied by
proteinuria for 6 years. Her conditions became severe in recent
2 years.
2. The patient said she
had to stop her menstruation for the praying activities. After
took the medicines for stopping menstruation, she suffered
lumbar pains, swelling eyelids and discomforts over her whole
general body. She accepted checks in Apollo Hospital in India
and the results as follows: proteinuria (+), urine creatinine
2.14, Scr 1.9 mg/dl, BU 45 mg/dl. Type-B ultrasonic: left kidney
8.6 cm, right kidney 8cm. Her condition was diagnosed as chronic
renal failure. Her condition was alleviated after taking some
medicines. Two years ago, her condition became severe; she went
to the Royal Hospital in Oman for checks, and the results showed
that her blood sugar was higher than before. Her condition now
was diagnosed as advanced renal failure and type
¢̣diabetics.
The hospital gave her some medicine for treatment and advised
her to take hematodialysis and kidney transplant. The patient
refused to do mematodialysis. Because her plasma renin activity
(PRA) was positive, she did not take kidney transplant. At
present, her kidney activity was only 9%.
3. When the patient was
hospitalized in our hospital, she suffered cramps and pains over
her lumbar part; when she suffered pains, her whole body was on
fever. The patient sometimes had dizziness, chest depression,
fatigue, and pains over her costal region, swelling eyelids and
tinnitus. Her above symptoms aggravated if she overworked. She
did not feel dry in her mouth and she liked to drink cold water
with large amount. Her appetite and sleep were good. Urine was
yellowish. She did not suffer from night urination. Bowel
movements were 1-2 times per day.
4. T: 36.5¡ăC R: 20
times/minute P: 68 times/minute BP: 142/80 mmHg
5. Her spirit activity
was good. She was a little bit plump. She grew normally. The
patient could move normally. There were pressing pains over her
left
hypochondrium. Knocking-on the kidney areas caused
pains. There was no edema over her two lower limbs. Her tongue
was dark with petechia on the top. Her
tongue coating was yellowish and greasy. Her pulse was sunken,
thready and weak.
6. Other
tests: Chloride 109 mmol/L, Urea 13.5 mmol/L, Creatinine 247
umol/L (Mar. 20, 2010 in Oman)
Diagnostic Basis:
TCM:
The patient¡¯s lumbar pain, dizziness and tinnitus were due to
insufficiency of kidney essence and marrow sea deficiency. Long
duration of disease is leading to kidney qi instability and
refined nutritious substances going to lower part; therefore
proteinuria appeared. Swelling eyelids, chest depression, dark
stagnated tongue with petechia
on the top, yellowish tongue and greasy tongue coating, as well
as sunken, thready and weak pulse were due to stagnation of damp
toxin obstructing the channels in the body. So, his condition
could be diagnosed as kidney turbidity, which was due to
insufficiency of kidney qi and damp toxin stagnating and
obstructing the channels. In addition, the patient suffered
polydipsia, in combination with lab checks of higher blood
sugar, and then the patient at the same time suffered from
diabetics.
Western Medicine:
The patient suffered from lumbar pains and swelling eyelids,
accompanied by proteinuria for 6 years, and her condition became
severer in the recent 2 years. In addition, according to the
examination result from the hospital, her condition could be
diagnosed advanced renal failure and type¢̣diabetics.
Diagnostic Differentiation:
TCM: The patient's condition
should be differentiated with
stranguria marked by chyluria. Both
two diseases have lumbar pain, swelling eyelids, proteinuira,
but for
stranguria marked by chyluria,
the patient usually suffer more times of urination, stanguria
and obstructing feeling of urinating.
Therefore, it was easy to differentiate them.
Western Medicine: Her condition should
be differentiated from nephrotic syndrome. Both two diseases all
have lumbar pains, swelling eyelids, proteinuira, but for
nephortic syndrome, there are large quantity of proteinuria,
evident edema, hyperlipemia and hypoproteinemia. So, it was easy
to differentiate them.
First Diagnosis:
TCM:
Kidney turbidity and diabetes.
Symptom identification:
the insufficiency of kidney qi as well as damp toxin stagnating
and obstruction the channels.
Western Medicine: Chronic renal
failure and Type
¢̣
diabetics.
Treatment strategy and
nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade
¢̣
care.
3. Companion.
4. Diet of low salt, low
fat, low sugar and low protein.
5. Pathogenesis: the
insufficiency of kidney qi as well we damp toxin stagnating and
obstructing the channels.
6. TCM strategy:
tonifying the kidney and clearing away dampness, removing stasis
and resolving toxin.
7. Herbal tea: one
dosage a day and drink twice
8. Acupuncture and
massage: once a day
9. Have more medical
examination if necessary.
Date: Oct. 23,
2011 Time: 10:00
am
This morning, Doctor Zhu
Ming paid a visit to the patient. The patient complained of
lumbar pains, and swelling eyelids, accompanied by proteinuria
for 6 years. Her condition became severe in the recent two
years. There was reoccurrence of convulsively pains over her
lumbar part. Her body temperature rose when the lumbar pains
happened. Sometimes she suffered dizziness, chest depression,
fatigue and pains over her costal region, swelling eyelids and
tinnitus. Her above-mentioned symptoms became severer when
overworked. She did not feel dry in her mouth and liked drinking
cold water. Appetite and sleep were good. Urine was yellowish
with normal quantity. She had no night urination. Bowel
movements were 1 or 2 times per day. Physique checks: She was a
little bit plump. There were pressing pains over her left
hypochondrium. Knocking-on the kidney areas caused
pains. She also had dark stagnated
tongue with petechia on the
top, yellowish tongue and greasy tongue coating, as well as
sunken, thready and weak pulse. Dr. Ming thought her condition
could be diagnosed as kidney turbidity, which was due to the
insufficiency of kidney qi as well as damp toxin stagnating and
obstructing the channels.
Date: Oct. 24,
2011 Time: 10:00
am
Lab checks:
Blood-R: RBC 5.35*1012/L
WBC: 10.48*109/L HB: 105g/L
Urine-R: GLU+- PRO:
+++ WBC: 0-1/HP
Blood: Cr: 468umol/L
BUN: 19.1 mmol/L UA: 502umol/L GLU: 7.40 ¡¡.
ECG: 1. Bradycardia, 2.
Change on SFT
B Ultrasonic: 1.
gallbladder stone 7*5cm 2. The two shrinking kidneys was
suffusing change. 3. There was no abnormal finding in the
liver, spleen and pancreas.
MRI: intervertebral disc
and
lumbar
vertebra
degenerations.
Added diagnosis:
Gallbladder stones and protrusion of lumbar vertebral discs.
Date: Oct. 25,
2011 Time: 10:00
am
The
patient said lumbar pains were reduced somewhat, but there still
existed swelling eyelids. Her tongue was dark with stasis with
yellowish and greasy coating. The pulse was deep, thready and
weak.
Date:
Oct. 29, 2011 Time:
10:00 am
The patient had stopped
eating foods with protein for 3 days now. Today urine creatinine
would be checked again. Back pains were reduced. Her tongue was
dark with stasis with yellowish and greasy coating. The pulse
was deep, thready and weak. The doctor advised her to stop
taking the diuretic for 24 hours and then checked the volume of
urine.
Date: Nov. 1,
2011 Time: 10:00
am
Check results: Ucr.
3041mmol/L Volume of urine for 24 hours: 1950 ml
The patient said eyelids
edema and lumbar pains were better than days before. The tongue
was dark with petechia
on the tip of the tongue. The coating was yellowish and greasy.
The pulse was deep, thready, slow and weak.
Date: Nov. 5,
2011 Time: 10:00
am
The
patient said back pains were reduced, but the eyelids were still
swelling. Test report from the No. 535 Hospital of PLA showed:
urine nitrogen 10.3mmol/L, creatinine 366 umol/L, UA 382
umol/L, Glu 7.03 mmol/L, triglyceride 2.82 mmol/L, HDLC 0.85
mmol/L, LDLC 2.14mmol/L, HGB 99 g/L, UGLU +-, UPRO +++. All the
index were changing better. The clearance rate of creatinine was
19.9%.
Date:
Nov. 7, 2011 Time:
10:00 am
The patient said there
still were back pains and swelling eyelids. She sometimes
suffered dizziness, tinnitus. The tongue and pulse were the same
as days before.
Date: Nov. 10,
2011 Time: 10:00
am
The patient said there
were slight improvements in the problem of lumbar pains and
swelling eyelids. She also said since the travel from Guangzhou
to Huaihua till now, she had tinnitus and dizziness. And now,
dizziness was reduced somewhat, while tinnitus in her right ear
was still severe. Her tongue was dark with
petechia on the
tip of the tongue. The coating was yellowish and greasy. Her
pulse was deep, thready, slow and weak.
Date: Nov. 13,
2011 Time: 10:00
am
Ms. Fatma said
dizziness, lumbar pains and swelling eyelids were better.
Tinnitus still existed. Her tongue was dark with
petechia on the
tip of the tongue. The coating was yellowish and greasy. Her
pulse was deep, thready, slow and weak.
Date: Nov. 16,
2011 Time: 10:00
am
The patient said
dizziness, lumbar pains and swelling eyelids were better. There
still existed tinnitus, severe in her right ear. Her tongue was
dark with petechia
on the tip of the tongue. The coating was greasy and slightly
yellowish. Her pulse was deep, thready, slow and weak, but the
kidney pulse was more powerful than before.
Date: Nov. 25,
2011 Time: 10:00
am
Feedback from the lab
analysis: HB 98.0, PRO 3+, Glu +, BLD +-, BUN 14.4 mmol/L,
Cr 377umol/L, GS 7.72 mmol/L, TG 3.27 mmol/L, HDL 0.97
mmol/L, LDL 2.19 mmol/L, AG 16.3 mmol/L
B ultrasonic:
gallbladder stone 6*3 mm
Date: Nov. 28,
2011 Time: 10:00
am
The patient¡¯s lumbar
pain and swelling eyelids kept turning better and tinnitus was
also better than before. Her tongue was dark with
petechia on the
tip of the tongue. The coating was greasy and slightly
yellowish. Her pulse was deep, thready, slow and weak.
Date: Dec. 1,
2011 Time: 10:00
am
The patient¡¯s condition
was stable. Her tongue and pulse were the same as days before.
Date: Dec. 2,
2011 Time: 14:00
am
Feedback of lab
analysis: HGB 99 g/L, TBA 12.4 umol/L, Urea 11.7 mmol/L, Cre
351 umol/L, UA 384 umol/L, TG 2.71 mmol/L, HDL 0.93 mmol/L, Cl
109 mmol/L, CO2CP 22.5 mmol/L, GLU +, PRO
+++, URO weak positive. The clearance rate of creatinine was
18.9%.
Date: Dec. 5,
2011 Time: 10:00
am
The patient complained
of lumbar pains and pains over the inside part of her left knee.
Other conditions were the same as before.
Date: Dec. 8,
2011 Time: 10:00
am
The patient¡¯s condition
was stable. BP: 140/80 mmHg. Her tongue was red with yellowish
tongue coating. Her pulse was deep, thready and weak. Back pains
sometimes were mild, sometimes severe. Tinnitus still existed.
There was no dizziness.
Date: Dec. 11,
2011 Time: 10:00
am
The patient said her
condition was stable. BP now was kept at 140-130/70-80 mmHg.
Tinnitus still existed. There was no dizziness. Her tongue was
red but slightly dark. There still was
petechia on the top of her tongue. The tongue
coating was yellowish. Her pulse was deep, thready and weak.
Date: Dec. 13,
2011 Time: 10:00
am
Blood sugar in the
morning was 11.8 mmol/L and the patient did not eat any food
before the test. There was not any change on her diet. She did
not take any sweet foods or food with high starch. She did not
suffer any special discomfort till now. The urine volume did not
increase. Bowel movement was normal. Sleep was good. Lumbar
pains, tinnitus and swelling eyelids were better.
Date: Dec. 16,
2011 Time: 10:00
am
Blood sugar test result before
taking any food in the morning was 11.7 mmol/L.
In the morning Dr. Ming
paid a visit to the patient, and she said lumbar pains and
swelling eyelids were better. Examination result of the function
of liver and kidneys: Urea 10.1 mmol/L, Cre 360 umol/L, UA 363
umol/L, PRO +++, GLU +-, WBC 1-2/HP. The clearance rate of
creatinine was 21.94%.
Date: Dec. 19,
2011 Time: 10:00
am
Blood sugar test result
before taking any food in the morning was 11.4 mmol/L. Bp 110/70
mmHg. Other conditions were just the same as above. The tongue
was red, but a little dark. The tongue coating was yellowish and
greasy. Her pulse was deep, thready and weak.
Date: Dec. 25,
2011 Time: 10:00
am
Blood sugar was 12.4
mmol/L in yesterday morning. Bp 130/80 mmHg. Other conditions
were just the same as above. The tongue was red, but a little
dark. The tongue coating was yellowish and greasy. Her pulse was
deep, thready and weak.
Date: Dec. 29,
2011 Time: 10:00
am
Blood sugar was 10.1
mmol/L in the morning. Bp 130/80 mmHg. The tongue and pulse were
the same as above.
Date: Jan. 3,
2012 Time: 10:00
am
The patient said pains
over her back and leg were reduced evidently. Swelling eyelids
also improved. There were no obvious improvements in other
conditions.
Date: Jan. 6,
2012 Time: 10:00
am
The patient¡¯s condition
was stable. The tongue was red but slightly dark with some
petechiae.
The tongue coating was yellowish and greasy.
Date: Jan. 9,
2012 Time: 10:00
am
The patient¡¯s condition
was stable. The tongue was red but slightly dark with some
petechiae.
The tongue coating was yellowish and greasy. Continue the
previous prescription.
Date: Jan.11,
2012 Time: 10:00
am
Ms. Fatma said lumbar pains, swelling eyelids were better than
before. There were no more pains over the hypochondrium. She got
recovered from tinnitus, dizziness and chest depression. Sleep
and appetite were good. Urination and bowel movement were
normal.
Petechiae
over the tongue surface were reduced somewhat. The tongue
coating was yellowish and greasy. Her pulse was deep, thready
and slow, but powerful than before. Report of January 8: WBC
6.04*109/L, HGB 97g/L, Glu +-, PRO +++, Scr 347
umol/L, urea nitrogen 11.8 mmol/L, UA 380 umol/L.
The clearance rate of creatinine was
23%, which was better than before. Ms. Fatma decided to leave
the hospital in the afternoon. Doctors¡¯ advice: take enough rest
and do not exercise too much, avoid food with high salt, sugar,
fat and protein. Take proper animal protein and reduce the
intake of plant protein. Avoid wind and cold. Keep good mood and
high spirit.
-------------
Mrs. Fatma Moosa Murad is 51 years
from Oman.
She is suffering from Kidneys
failure for the last seven year.
Her kidneys are shrinking day by
day and the last examination in Oman and Thailand she was told
that her Kidneys function is 9 to 10% only and she was told to
start have Kidneys dialysis.
She felt very badly to go all these
hassle of having Kidneys dialysis and Kidney transplant even
though one of her daughter she was willing to donor one of her
Kidney to her mother.
I started to convinced her eldest
daughter for TCM treatment and to come to Huai Hua-China.
It took several weeks till all the
family member to agreed cause TCM treatment was very new to them
and was not easy to accept.
We travel from Oman and reached
here on 22nd October 2011, and on 23rd October she went to
Military Hospital in Huai Hua to have full medical check, MRI,
EEG, Ultra Sound, Blood and Urine tests.
After receiving medical result we
found her BUN (Proteins), Creatinine and Urea were extremely
high some went near to 300%.
She started her TCM medical at Red
Cross hospital on the first day.
After 12 days on 3rd November she
went again to Military Hospital in Huai Hua to have Blood and
Urine test upon received the results we found there was a very
good progress cause BUN, Creatinine and Urea showed start to
come down and some came down on big scale.
If the result continue to come like
this I hope she should recovered at least few percentage in 3
months.
I hope Red Cross will try their
best to get best treat and hopefully she will be cure soon.
Jamal from Oman
Nov. 7, 2011
¡¡
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