On June 15, 2012, Ali, from Bahrain, who had suffered from
dizziness and nausea for 9 years, back pains for 5 years and
cough for one and half years, was hospitalized in our hospital.
He had achieved great improvement after two and half months TCM
treatment.
Record of Hospitalization
Name:
Ali Sex: Male
Age:
39 Marital Status:
Unmarried
Nationality:
Bahrain Date of Admission: June
15, 2012
Companion:
Family
First Medical Record
Date:
Jun. 16, 2012 Time: 10:00
a.m.
Ali, male, a 39-year-old man, had suffered from dizziness and
nausea for 9 years, back pain for 5 years and cough for one and
half years. He was hospitalized in our hospital for treatment at
7 p.m. on June 15, 2012.
Essential for Diagnosis:
1. The patient had suffered from dizziness and nausea for 9
years, back pains for 5 years and cough for one and half years.
2. When he came to our hospital, he had such symptoms as
dizziness, chest depression, nausea, coughing with phlegm and
occasional headache. He had hot pains over his lumbar. He was
easy to be tired. Appetite was good. Sleep was normal. Bowel
movement was two times per day. Urination was normal with
yellowish color. He also had occasional diarrhea. He felt
dryness in his mouth and liked drinking warm water. He suffered
feeling of regurgitation one or two
hours after meal.
3. T: 36.3＜C R: 20 times/minute P: 80 times/minute BP:
130/80mmHg
4. He grew normally with common nutrition and he was a little
bit fat. His sense and speaking were normal. His mind was clear.
He had chronic sick facial complexion. He suffered fist
percussion over the kidneys. No edema was showed over her lower
limbs and eyelids. His tongue was red and thin with teeth marks
over the side of his tongue. His tongue coating was few. His
pulse was deep, thready and weak.
Diagnostic Basis:
TCM:
Phlegm turbidity of the patient affected the Yang-Qi, so he had
dizziness. Damp phlegm blocking the middle-warmer, and the
disharmony of the qi of the spleen and stomach caused chest
depression, nausea and regurgitation after meal. Spleen,
pertaining to earth was too powerful than the kidneys, which
pertains to water, therefore, the symptom of lumbar pains
appeared. According to the above analysis, his condition should
be consumptive disease, due to phlegm turbidity blocking
middle-warmer, yin-deficiency of kidneys and lungs.
Western Medicine:
The patient had suffered from dizziness, nausea and lumbar pains
for 5 years and cough for one and half years. He had fat body
figure, fist percussion over the kidneys and no edema over his
lower limbs. He also had some exact examinations at local
hospital of his country.
First Diagnosis:
TCM: Consumptive disease
Symptom identification: Phlegm turbidity blocking the
middle-warmer, deficiency of the kidneys and lungs
Western medicine diagnosis: chronic renal failure
Treatment strategy and nursing:
1. Routine care of traditional Chinese internal medicine.
2. Grade
Å
care.
3. Common diet
4. TCM strategy: resolve
5. Herbal tea: one dosage a day and drink twice
6. Acupuncture and massage: once a day
7. Have more medical examination if necessary.
Date: Jun. 17, 2012
Time: 9:00 a.m.
Dr. Ming paid a visit to this patient this morning. The patient
complained that he suffered dizziness and nausea for 9 years,
lumbar pains for 5 years and cough for one and half years. He
had heat feeling over his lumbar pain area. He suffered feeling
of regurgitation one or two hours after meal. He felt dryness in
his mouth and liked to drink warm water. There were pressing
pains over his lumbar part. No edema was presented over his
lower limbs and face. His tongue was red and thin with few
coating. There were teeth marks over his tongue sides. Her pulse
was deep, thready and weak. According to the theory of TCM, Dr.
Ming thought that the patient¨s condition should be consumptive
disease, due to phlegm turbidity blocking the middle-warmer as
well as deficiency of the kidneys and lungs.
Date: Jun. 21, 2012
Time: 9:00 a.m.
The patient complained dizziness and headache. He suffered heat
pains over the first metatarsal bone of his left body side.
Nausea and cough turned better. Lumbar pains were reduced
somewhat. Manifestation of his tongue and pulse was the same as
before.
Date: Jun. 24, 2012
Time: 9:00 a.m.
The patient complained that he still suffered from dizziness,
headache and nausea. His tongue was red and thin, with few
tongue coating. Teeth marks were presented over the edges of his
tongue. Her pulse was deep, thready and weak.
Date: Jun. 28, 2012
Time: 9:00 a.m.
The patient complained swelling pains over her left foot, but
better than days before. His right foot was sprained yesterday,
and right now, it is swelling and painful.
Date: Jul. 1, 2012
Time: 9:00 a.m.
No more pains over the patient¨s feet.
Date: Jul. 4, 2012
Time: 9:00 a.m.
The patient felt no more pains over his feet. He still had
coughing and abdominal distension. He had no bowel movement for
three days. His tongue was red and thin, with few tongue
coating. Teeth marks were presented over the edges of his
tongue. Her pulse was deep, thready and weak.
Date: Jul. 8, 2012
Time: 9:00 a.m.
The patient said he already had bowel movement, but he was still
suffering coughing, with yellowish or whitish phlegm. Running
nose was better. His tongue was red with few coating. Teeth
marks still presented. His pulse was thready.
Date: Jul. 12, 2012
Time: 9:00 a.m.
The patient complained he was still suffering coughing, with
yellowish or whitish phlegm. No more running nose. He still
suffered dry nausea. Manifestation of tongue and pulse was the
same as before.
Date: Jul. 15, 2012
Time: 9:00 a.m.
The patient complained that when he coughed, the phlegm was
sticky and yellowish, and he felt chest pains. He suffered pains
over his kidney areas.
Date: Jul. 18, 2012
Time: 9:00 a.m.
Cough and chest pains were better than days before. Pains over
his kidney areas were reduced.
Date: Jul. 25, 2012
Time: 9:00 a.m.
The patient complained that his right ankle joint was painful
and hot. He also felt slightly pains over his lumbar. His tongue
was red with few coating and teeth marks. His pulse was deep
wiry and rapid.
Date: Jul. 28, 2012
Time: 9:00 a.m.
Ankle joint pains were reduced a lot. Slight pains happened over
his lumbar part. Manifestation of his tongue and pulse was the
sa.m.e as before.
Date: Aug. 1, 2012
Time: 9:00 a.m.
The patient said there were no more pains over his ankle joint,
but still slight pains over his back. His tongue was red with
few coating and teeth marks. His pulse was deep and thready.
Date: Aug. 5, 2012
Time: 9:00 a.m.
Asked him to do the following exa.m.inations: blood routine and
urine routine, liver and kidney functions,
B ultrasound over his kidneys.
Date: Aug. 11, 2012
Time: 9:00 a.m.
The patient had no more symptoms of nausea, regurgitation and
dizziness, but slight cough with whitish phlegm. He still
suffered back pains.
Date: Aug. 15, 2012
Time: 9:00 a.m.
The patient still suffered from slight cough, but expectoration
was better.
Date: Aug. 18, 2012
Time: 9:00 a.m.
The patient did not have cough now, but felt some bit of phlegm
in his throat. There were no more dizziness, nausea and
vomiting. Slight pains still showed over his back.
Date: Aug. 24, 2012
Time: 9:00 a.m.
The patient complained that his condition was the sa.m.e as days
before.
Date: Aug. 26 2012
Time: 9:00 a.m.
