Name: Farankee                                                            Sex: Female

Age: 65                                                                         Marital Status: Married

Nationality: Bahrain                                                      Date of Admission: Feb. 10, 2014

Companion: her son

First Medical Record

Date: Sep. 7, 2014                                Time: 14:00 pm

Farankee, female, 65 years old, had suffered from dizziness for 10 years. Her condition got worse. Her ankle joints had repeated edema for 3 years. The patient was hospitalized in our hospital with “Kidney Failure” for TCM treatment at 21:00 pm on Feb. 10, 2014.

Essential for Diagnosis:

1. The patient had suffered from dizziness for 10 years. Her condition got worse. Her ankle joints had repeated edema for 3 years. 2 years ago the patient was allergic to fish and shrimps. At that time she had red skin over her whole body and itching. She took some western medicines to control the allergy.

2. The patient had hypertension for 10 years. She always controlled her diet strictly. She did not take any medicine for her hypertension. But 3 years ago her ankle joints got edema, and she started to take the medicine for her high blood pressure. At the same time she had cataract and she had an operation. From that time to now she always takes the following medicines: Natrilix, one capsule a day; Dilatrend 25mg, twice a day, one capsule per time; Norvasc 5mg*2#, irregular taking; Hydralazine, one table per time, twice a day. In the first half of this year the patient took the blood test, it reported her hemoglobin was reduced to 11. She took the medicine Mircera for several months, but she has stopped taking this medicine. On Dec. 20, 2013 her creatine was 251. And on Feb. 2 of this year the report was 237. And 2 years ago her weight was 72 kgs, while her weight has been reduced to 55 kgs. When she came to our hospital for treatment, she had the following symptoms such as dizziness, edema over her ankle joints, stiff muscles of her four limbs. And she was afraid of cold. Occasionally the patient had difficult breath, insomnia and dreaminess. She felt thirsty and she preferred to warm drinks. If she had more urine and the color was a little clearer.

3. T: 36.4°C   R: 20 times/minute    P: 80 times/minute   BP: 140/74mmHg

The patient had normal growth, physique and spiritual activity, while with chronic disease face. She cooperated with doctors when the physical examinations were made. Her eyes were flexible, and her face was a little white. There was no oral ulcer. Her swallowing ability was normal. The thyroid was not swelling. The jugular vein was of no backflow. She had normal thorax. Her skin was also normal. And her respiratory movement was normal. The sound of breath was normal, without rhonchi. Her abdomen was soft, and the color of skin had no any change. There were no pressing pains over her stomach. Murphy’s sign was negative. Her abdomen had no pressing pains and rebound tenderness. The bowel sound had no hyperfunction. The temperature of four limbs was a little low. The ankle joints of her lower limbs had no obvious edema. There were no pains over her back and waist. But her upper back near the scapular had some pains and she felt discomfort. The pathologic reflex of nervous system had not been drawn out. Her tongue fur was greasy and the color was yellow. Her tongue was red. Her pulse was string-like.                                                                                                           

4. Examination: 1) creatine: 251 (Nov. 20, 2013); 2) creatine: 237 (Feb. 2, 2014)

Diagnostic Basis:

TCM: 1) Hyperactivity of liver yang     2) kidney failure: The TCM diagnostic basis was deficiency of kidney yin, wind yang harassing the upper body. She suffered from dizziness for 10 years, and the ankle joints had edema for 3 years. Occasionally she had difficult breath, insomnia and dreaminess. She preferred to warm drinks. She always felt thirsty. Her tongue fur was greasy and the color was yellow. Her tongue was red. Her pulse was string-like. She was old when she suffered from this disease. She had deficiency of both kidney yin and kidney yang. Her four limbs were cold because of deficiency of kidney yang, while the deficiency of kidney yin could lead to deficiency of liver yin. She had dizziness because of ascendant hyperactivity of liver yang. Insufficiency of the liver and kidney led to loss of nourishment for the eyes, so she had cataract. And the deficiency of the kidney led to her difficult breathing.

Western Medicine: According to her history of chronic dizziness and edema and the report of creatine, she suffered from kidney failure.

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ care, companion.

3. Have more medical examination: Blood routine test, Urine routine test and biochemical examination.

4. TCM strategy: fortifying the spleen and warming the kidneys, transforming stagnation and discharging turbidity.

5. Herbal tea: one dosage a day and drink twice

6. Acupuncture and massage: once a day

7. Taking low salt, low fat and low cholesterol diet.

8. Do more exercises.

9. Closely monitoring her blood pressure and blood sugar.

Date: Feb.11, 2014                                    Time: 10:00 a.m.

Dr. Peng, doctor-in-charge, paid a visit to the patient. The patient suffered from dizziness for 10 years, and the ankle joints had edema for 3 years. Occasionally she had difficult breath, insomnia and dreaminess. She preferred to warm drinks. She always felt thirsty. Her tongue fur was greasy and the color was yellow. Her tongue was red. Her pulse was string-like. She was old when she suffered from this disease. She had deficiency of both kidney yin and kidney yang. Her four limbs were cold because of deficiency of kidney yang, while the deficiency of kidney yin could lead to deficiency of liver yin. She had dizziness because of ascendant hyperactivity of liver yang. Insufficiency of the liver and kidney led to loss of nourishment for her eyes, so she had cataract. And the deficiency of the kidney led to her difficult breathing.

Date: Feb.12, 2014                                    Time: 10:00 a.m.

There was no special change and discomfort. The patient felt that her sleeping was better.

Date: Feb. 13, 2014                                   Time: 10:00 a.m.

The blood pressure was 150/70 mmHg, The report of examination: TBIL: 4.0; D-BIL: 0.7; CK: 335; BUN: 19.27; Creatine: 205.

Date: Feb.17, 2014                                    Time: 10:00 a.m.

Recently the blood pressure was 160-150/80-70mmHg or so. The blood sugar was 6.0 or so. The vital signs of the patient were stable. There was no obvious discomfort. The pains of her back were relieved. Her orbit were obviously dark. The patient had obvious puffiness uder-eye.

Date: Feb. 20, 2014                                   Time: 10:00 a.m.

The blood pressure was 150/80 mmHg. The blood pressure was stable. The blood sugar was 7.30. There was no obvious discomfort. Her diet was normal, but her liver pulse was weak.

Date: Feb. 24, 2014                                   Time: 10:00 a.m.

The vital signs of the patient were stable. Dr. Peng decided to take the blood and biochemical examination.

Date: Feb. 28, 2014                                   Time: 10:00 a.m.

The report showed that the UA was 296, the creatine was 181. The latest report the creatine was 205. Obviously the patient was better according to the report of the blood and biochemical test.

Date: Mar. 1, 2014                                    Time: 7:30 p.m.

The patient fell down accidentally. She felt the pains over her right head and face, as well as her knees. But the pain area had no bleeding and mass. The patient said there were no dizziness, no vomiting, no nausea and palpitations. And the blood pressure was 165/75 mmHg, P 64 times/min. The patient was conscious, and she cooperated with doctor on examination. But her spirit was stressed, and she was afraid of cold. In the afternoon she did not take the medicine for her hypertension. Doctor asked her to remember to take the medicine, and the nurse gave the Yunnan Baiyao spray for the wounded part of her knees. And the cold sensation was better. If the patient fell any discomfort, the patient or her son should tell the doctor timely.

Date: Mar. 02, 2014                                   Time: 10:00 a.m.

The patient said there was no discomfort. The blood pressure was 160/68. The blood sugar was 5.6. Her sleeping and spirit were good. The patient could not differentiate her wounds. The pulse was weak, but it was powerful.

Date: Mar. 05, 2014                                   Time: 10:00 a.m.

There was no discomfort. Her blood pressure and blood sugar were stable. The blood sugar was 5.6. The blood pressure was 165/70 mmHg. Her appetite was not bad. The patient said she had frequent urination at night. And her body was cold.

Date: Mar. 10, 2014                                  Time: 10:00 a.m.

The vital signs of the patient were stable. Her sleeping and appetite were good. The blood sugar was 5.20, the blood pressure was 158/70 mmHg. Doctor asked to take the test for creatine and hemoglobin.

Date: Mar. 15, 2014                                 Time: 10:00 a.m.

The patient’s conditions were stable and kept turning better.

Date: Mar. 24, 2014                                Time: 10:00 a.m.

The report of creatine showed it was 109 umol/L. It was almost normal. The patient felt fine without discomfort. Her sleeping was good.

Date: Mar. 24, 2014                                 Time: 10:00 a.m.