Brief
Summary:
Mr. Khalil, from
Bahrain, had been suffering from hypertension for more than 25
years and in rent years he suffered from diabetes. At present,
the patient complained of weakness over his general body and
severe night urination problem. He was hospitalized in our
hospital on April 6, 2011 for TCM treatment. He achieved great
improvement in his condition after one month TCM treatment with
the help of herbal tea, acupuncture, massage etc.
Record of
Hospitalization
Name:
Khalil Sex:
Male
Age:
60 Marital
Status: Unmarried
Nationality:
Bahraini Date of Admission:
Apr. 6, 2011
Companion:
Family
First Medical Record
Date:
Apr. 7, 2011 Time:
10:00 am
This 60-year-old
gentleman had been suffering from hypertension for more than 25
years and in recent years he suffered from diabetes. At present,
the patient complained of weakness over his general body and
severe night urination problem. The patient was hospitalized in
our hospital for TCM treatment at 19:00 am on Apr. 6, 2011.
Essential for Diagnosis:
1. The patient had been
suffering from weakness over his whole general body. He had
abnormal urine of 8-10 times per day, and his night urination
was 3-4 times. He had edema over his lower limbs, especially
over the joints of his ankles.
2. The patient was
attacked by hypertension 25 years ago, and at that time, it was
not very severe. Later on, he took some western medicines for
his hypertension. His blood rate sometimes was high, and
sometimes low. It was very unstable. In recent years, he
suffered from diabetes. Years ago, he sometimes had headaches,
after took the anti-hypertension medicines, the symptom of
headache disappeared.
3. When the patient was
hospitalized in our hospital, he had heavy nasal blocking,
easily-catching cold and loss of smell, with occasional
coughing. He did not have phlegm. His nasal mucosa showed
hyperemia and edema. The lymph gland in his throat was two
degrees enlargement. The lymph follicle was swelling evidently.
He did not suffer from fever. His pulse was floating. His tongue
coating was thin and yellow.
4. T: 36.4¡ãC R: 20
times/minute P: 80 times/minute
5. His spirit activity
was good. He grew normally. His diet was of common nutrition. He
had fine sense. The motion of his four limbs was flexible. He
had gray facial complexion with a slightly plump body. His
jugular reflux was slightly positive.
Sound of breathing in the lungs was clear, without any rhonchi.
The formation and size of his thorax were normal. His abdomen
was soft. There was no enlargement of his liver and spleen.
There were no
abdominal jugular reflux sign and Murphy¡¯s sign.
6. His
four limbs were soft without any limitation of movement, but
there was edema in his lower limbs, in particular the joints of
his ankles.
Diagnostic Basis:
TCM:
The patient suffered from weakness over his whole body. His
urination was abnormal with night urination of 3-4 times. There
was edema in his lower limbs, in particular the joints of his
ankles. His blood sugar was little high with the blood pressure
of 174/90. His pulse was wiry. His tongue was slightly red with
yellow and greasy tongue coating. So, his condition could be
diagnosed as edema.
Western Medicine:
The patient suffered from weakness over his whole body. His
urination was abnormal with night urination of 3-4 times. There
was edema in his lower limbs, in particular the joints of his
ankles. His blood sugar was little high with the blood rate of
174/90. His pulse was wiry. His tongue was slightly red with
yellow and greasy tongue coating. So, his condition could be
diagnosed hypertensive nephropathy.
Diagnostic Differentiation:
TCM: The patient¡¯s condition
should be differentiated with distension. As to the symptoms of
edema, there usually appear swellings on patient¡¯s face, head,
eyelids, limbs, abdomen and back, or even dropsy on the
patient¡¯s whole general body. Patient with severe edema may
suffer from ascites and hydrothorax. While ascites is the main
symptom of distention and when it becomes worse, swelling also
could appear on limbs or even the whole body. The swelling of
Khalil¡¯s case only happened on his feet and legs without any
shifting dullness in his abdomen. Abdominal distension was not
very severe. Therefore, it was easy to differentiate them.
Western Medicine: His condition should
be differentiated from the rheumatic heart disease edema. As to
the rheumatic heart disease edema, there exist pains on the
joints of the body. The positive rheumatic factors help to make
differentiations. So, it was easy to differentiate them.
First Diagnosis:
TCM:
Edema.
Symptom identification:
the insufficiency of the liver and kidney, the qi vacuity and
blood staisis.
Western Medicine: hypertensive
nephropathy.
Treatment strategy and
nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade
¢ò
care.
3. Companion.
4. Diet of low salt and
low fat.
5. Pathogenesis: the
insufficiency of the liver and kidney, the qi vacuity and blood
stasis.
6. TCM strategy:
promoting the circulation of blood and transforming stasis,
nourishing the liver and kidney.
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: Apr. 7,
2011 Time: 10:00
am
This morning, Professor
Yang Qingzhi paid a visit to the patient. The patient complained
of weakness over his whole body. His urination was abnormal with
night urination of 3-4 times. There was edema in his lower
limbs, in particular the joints of his ankles. His blood sugar
was little high with the blood pressure of 170/90. His pulse was
wiry. His tongue was slightly red with yellow and greasy tongue
coating. Professor Yang thought, according to the symptoms of
the tongue and pulse, the patient¡¯s condition was caused by the
insufficiency of the liver and kidneys, the qi vacuity and blood
stasis. Therefore, the treatment should be promoting the
circulation of blood and transforming stasis, nourishing the
liver and kidneys.
Date: Apr. 10,
2011 Time: 10:00
am
The patient said edema
over his lower limbs was reduced a lot. There were wrinkles over
the skin on his lower limbs.
Date: Apr. 15,
2011 Time: 10:00
am
The
patient said edema of his lower limbs disappeared and the
wrinkles of the skin were normal now. His pulse was wiry. His
tongue was slightly red with yellow tongue coating.
Date:
Apr. 20, 2011 Time:
10:00 am
The patient had high
spirit these days. Sleep was good. There was no edema any more.
The blood pressure was 170/90. His pulse was a little bit wiry.
His tongue was of light red with slightly tongue coating.
Date: Apr. 23,
2011 Time: 10:00
am
The patient¡¯s blood
pressure still was 170/90. Other conditions were stable. His
tongue coating was slightly yellow. His pulse was slight wiry,
and his tongue was slightly red.
Date: Apr. 27,
2011 Time: 10:00
am
The
patient today felt fatigued, due to the cold he caught recently.
He coughed with white phlegm. Sleep was not good. His tongue
coating was white. His pulse was a little bit floating. His
tongue body was slightly red.
Date:
Apr. 30, 2011 Time:
10:00 am
The patient got
recovered from cold without the sense of fatigue. His blood
pressure was now 160/80. His spirit and appetite were good.
Date: May 3,
2011 Time: 10:00
am
His blood pressure today
was 170/90. Spirit and appetite were good. Sleep in the recent
days was good. His tongue was slightly red with slightly white
tongue coating. His pulse was a little bit wiry.
Date: May 6,
2011 Time: 10:00
am
Khalil¡¯s condition
improved greatly than he came to our hospital. The patient
decided to leave the hospital today. After TCM treatment in our
hospital for 31 days, he had recovered from edema. He no longer
felt weak. His urinary problem was improved a lot. Now his did
not have night urination any more. His problem of urinary
endless was improved a lot.
Doctor¡¯s advice after
leaving hospital:
1. Avoid wind-cold, take
care of cold.
2. Take herbal medicine
back for continuing treatment.
3. Diet of low salt and low fat. ¡¡
