Brief Summary:
On September 23,
2013, Sophie, from Israel, who had been suffering from repeated
dizziness for 5 years, accompanied by blurred vision and
vomiting, was hospitalized in our hospital. She achieved great
improvement after three months TCM treatment with the help of
herbal tea, acupuncture and massage.
Record of
Hospitalization
Name: Sophie
Sex: Female
Age:
50 Marital Status: Married
Nationality:
Israeli Date of Admission: September 23, 2013
Companion:
Her husband
First Medical Record
Date: Sep. 23, 2013 Time: 12:00
a. m.
This 50-year-old lady had been suffering from repeated dizzness
for 5 years, accompanied by blureed vision and vomiting. The
patient was hospitalized in our hospital for TCM treatment at 12
a.m. on September 23, 2013.
Essential for Diagnosis:
1.
The patient had been suffering repeated dizziness for 5 years,
accompanied by blurred vision and vomiting, and seeing things
rotating. 17 years ago, she suffered a car accident, and her
cervical vertebrae were injured. There were pains over her
cervical vertebra. Right now, there were pains over the right
side over her neck. She has the medical history of asthma, and
when she caught cold, asthma happened.
2.
When she came to our hospital, she suffered dizziness, blurred
vision, seeing things rotating, nausea and vomiting. Her
conditions happened repeatedly, sometimes several minutes,
sometimes 6-7 days. When she turned her neck, the above symptoms
happened. She felt puffy eyes. Sometimes she suffered shortness
of breath, tinnitus and cough. She had night urinations for 2-3
times every night. She was afraid of cold. Bowel movement was
normal. The feeling over her lower abdomen almost went away.
There were numbness and pains over her lumbar part.
3.
T: 36.3＜C R: 20 times/minute P: 80 times/minute BP:
110/80mmHg
5.
The patient grew normally with a little fat body figure. Her
spiritual activity was good. There were several pressing pain
points over her body. Her tongue was red with white and thin
coating. There were teeth marks over her tongue. Her pulse was
deep, thready and slightly slippery.
Diagnostic Basis and Differentiation:
TCM: The
patient had suffered from dizziness, blurred vision, rotating
views, vomiting for 5 years. She also suffered shortness of
breath, tinnitus and uncontrollable urination, afraid of cold,
back pains. Her tongue was red with white and thick tongue
coating. There were teeth marks on her tongue edges. Her pulse
was deep, thready and slightly slippery. Her condition belongs
to the category of vertigo in TCM. She also had the medical
history of asthma. Turbid phlegm and wind phlegm attack upwards
the orifices, and then vertigo problem occurred. Stagnation of
turbid phlegm in middle-warmer and disharmony of the ascending
and descending function of the qi of spleen and stomach caused
nausea and vomiting. The patient was slightly old and the
kidney-yang was sufficiency, then the symptoms of back pains,
aversion to cold, tinnitus, uncontrollable urination occurred.
Therefore, her condition should be vertigo, due to stagnation of
turbid phlegm in middle-warmer and yang deficiency of the spleen
and kidneys.
Western Medicine:
1. Dizziness, seeing things rotating and vomiting for 5 years.
2.
Turning her neck too fast, her symptoms occurred. Puffy eyes,
shortness of breath, tinnitus, uncontrollable urination.
First Diagnosis:
TCM: Vertigo.
Symptom identification: stagnation of turbid phlegm in
middle-warmer and yang deficiency of spleen and kidneys.
Western medicine: M└ni┬re's Disease
Treatment
strategy and nursing:
1.
Routine care of traditional Chinese internal medicine.
2.
Grade
Å
care.
3.
Pathogenesis: stagnation of turbid phlegm in middle-warmer and
yang deficiency of spleen and kidneys.
4.
TCM strategy: removing dampness and phlegm, warming the
kidney-yang.
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: Sep. 23,
2013 Time: 12:00 a. m.
Dr. Zhu Ming, doctor
paid a visit to the patient. The patient complained that she
suffered dizziness, blurred vision, rotating views, vomiting for
5 years. She also suffered shortness of breath, tinnitus, and
uncontrollable urination, aversion to cold, back pains. Her
tongue was red with whitish and thick coating. There were teeth
marks over her tongue surface. Her pulse was deep, thready and
slightly slippery. Turbid phlegm and wind phlegm attack upwards
the orifices, and then vertigo problem occurred. Stagnation of
turbid phlegm in middle-warmer and disharmony of the ascending
and descending function of the qi of spleen and stomach caused
nausea and vomiting. The patient was slightly old and the
kidney-yang was sufficiency, then the symptoms of back pains,
afraid of cold, tinnitus, uncontrollable urination occurred.
According to the theory of TCM, her condition should be vertigo,
due to stagnation of turbid phlegm in middle-warmer and yang
deficiency of spleen and kidneys. The treatment for her
condition was to remove dampness and phlegm, as well as to warm
the kidney-yang.
Date: Sep. 24, 2013 Time: 10:00
a. m.
There were no obvious change about her bowel movement and
urination.
Date: Sep. 25, 2013 Time: 10:00
a. m.
The
patient said he felt better over her back movement.
Date: Sep. 26, 2013
Time: 10:00 a. m.
The
patient said she felt slightly dizziness. Urine was clearer than
before, but no obvious change about her bowel movement.
Date: Sep. 27, 2013 Time: 10:00
a. m.
The
patient said dizzness and headache were improved a lot. Urine
was clearer than before, but no obvious change about her bowel
movement. Sleep was good.
Date: Sep. 30, 2013 Time: 10:00
a. m.
The
patient said appetite and sleep were normal. Her weight
decreased 1KG. Urination and bowel movement were normal. Spirit
was better.
Date: Oct. 3, 2013 Time: 10:00
a. m.
The patient said she suffered diarrhea yesterday.
Date: Oct. 5, 2013 Time: 10:00
a. m.
The patient still
suffered diarrhea, but without headache or dizziness. Her pulse
was still deep and thready.
Date: Oct. 8, 2013 Time: 10:00
a. m.
The
patient, today, still suffered slight diarrhea.
Date: Oct. 11,
2013 Time: 10:00 a. m.
Diarrhea stopped. There was no obvious change over her weight.
The distension feeling over her stomach decreased somewhat. The
heavy feeling over her lower limbs was reduced.
Date: Oct. 14, 2013 Time: 10:00
a. m.
The patient felt more
lightness over her hands and legs, less heavy sensation than
before. There was no obvious discomfort over her body. There
were no dizziness and tinnitus. Her sleep and appetite were
good. She has stopped use of female hormone. The prescription
was still to tonify the kidneys and spleen as well as to soothe
the liver and improve the circulation of the qi.
Date: Oct. 18, 2013 Time: 10:00
a. m.
She had slight
constipation. She felt tired over her hands and feet. Distension
appeared on her abdomen part. Her pulse was deep and thready.
She did not suffer dizziness and headache. There was not much
urine.
Date: Oct. 22, 2013 Time: 10:00
a. m.
She had slight
constipation. She did not feel obvious distension over her
abdomen. Her pulse was float and wiry.
Date: Oct. 26, 2013 Time: 10:00
a. m.
Headache went away. The
patient said from this month on, she had whites. Appetite and
sleep were normal. Pains over her shoulders were alleviated. Her
pulse was deep and thready.
Date: Nov. 6, 2013 Time: 10:00
a. m.
The patient did not
catch cold or suffer dizziness, but there still were tense
feeling over her neck and shoulders. Appetite was a little down
than before. Her sleep was good. She had stopped the use of
female sex hormone for almost one month. She did not feel any
discomfort.
Date: Nov. 10, 2013 Time:
10:00 a. m.
Today, the patient came
with the period. She did not feel any headache, dizziness, or
abdominal pains.
Date: Nov. 14, 2013 Time:
10:00 a. m.
The period of the
patient stopped. She did not feel any discomfort. The
prescription was still to reduce phlegm and tonify spleen as
well as to free the circulation of blood and remove stasis of
blood.
Date: Nov. 17, 2013 Time:
10:00 a. m.
The patient did not feel
headache. She still felt tense feeling over her back and lumbar
part.
Date: Nov. 22, 2013 Time:
10:00 a. m.
The patient did not feel
headache or any discomfort. No more tense feeling over her back
and lumbar part.
Date: Nov. 26, 2013 Time:
10:00 a. m.
Appetite of the patient
was increased. Her pulse was deep and thready. No more pains
over her shoulders.
Date: Nov. 30, 2013 Time:
10:00 a. m.
The patient did not feel
headache. Her appetite and sleep were normal. There was no
obvious discomfort.
Date: Dec. 5, 2013 Time: 10:00
a. m.
The patient did not feel
any discomfort. She still felt about her obesity problem. She
did not feel headache and dizziness for long time since the
treatment started.
Date: Dec. 12, 2013 Time: 10:00
a. m.
The patient was in the
time of her period. She felt headache last night. Her pulse was
weak, especially her liver pulse.
Date: Dec. 16, 2013 Time: 10:00
a. m.
Days before, the patient
had period. She only suffered headache. After taking some herbal
tea, pains disappeared. Her pulse was still wiry.
Date: Dec. 20, 2013 Time: 10:00
a. m.
The patient only
suffered watery bowel movement. She had no more headache and
insomnia.
Date: Dec. 25, 2013 Time: 17:00
p. m.
The patient decided to leave our hospital
today. After TCM treatment for more than 3 month, her symptoms
almost got cured. She was satisfied with our TCM service. And
she decide took some medicine back to continue the treatment.
