Brief Summary:
On June.
08, 2014, Yuzhu Guo, came from Indonesia, who suffered from
dizziness and tinnitus for 5 years. She was hospitalized in our
hospital. She got some improvement after 16 days TCM treatment.
Record of
Hospitalization
Name:
Yuzhu Guo
Sex: Female
Age:
69 Marital Status: Married
Nationality:
Indonesia
Date of Admission: Jun. 08, 2014
Companion:
Nobody
First Medical
Record
Date:
June 08, 2014 Time: 10:00 a.m.
Yuzhu Guo, female,
69 years old, had suffered from dizziness and tinnitus for 5
years. The patient was hospitalized in our hospital for TCM
treatment at 10:00 a.m. on June 08, 2014.
Essential for
Diagnosis:
1. The
patient had suffered from dizziness and tinnitus for 5 years.
And it was rotatory vertigo, but with no vomit, no palpitations
and no insomnia. There were no medicine and food for her to get
allergy response.
2. The
patient was 69 years old now. Before she had a good health. She
had a child with normal childbirth. She had hypotension. 5 years
ago the vertigo and tinnitus began to attack her. But recently
she had dizziness, tinnitus, pains over her cervical spine and
thoracic vertebra, palpitations and insomnia. She felt sore all
over her body. There was no dry mouth. And her appetite was
normal. The color of urine was white. And her bowel movement was
normal, but a little soft.
3. T:
36.3＜C R: 20 times/minute P: 80 times/minute BP:
112/56mmHg
The patient had
normal growth, physique and spiritual activity, while with
chronic disease face. There was no hyperaemia and edema in her
throat. Her neck was soft without resistance stiffn. Sound of
breathing in her lungs was clear. Her chest was symmetrical.
Rhythm of her heart was a little slow. Heart rate was irregular.
Her abdomen was soft without pressing pains and rebound
tenderness. The result of Murphy¨s sign was negative. The
meningeal irritation syndrome was also negative, without the
other pathological reflex. The tongue was thin with white
coating. The pulse was deep, wiry and irregular.
4. Examination:
The result of X-ray showed that her thoracic vertebra and
intervertebral disc degenerated.
Diagnostic Basis:
TCM:
Dizziness and tinnitus
Western Medicine:
Dizziness and tinnitus
Treatment
strategy and nursing:
1. Routine
care of traditional Chinese internal medicine.
2. Grade
Å
care and common diet.
3.
To apply for the
three routine inspection, the function of kidneys and liver.
4. Herbal
tea: one dosage a day and drink twice
5. Acupuncture and
massage: once a day
6. Relax mind,
regulate emotion and living timetable.
Date: Jun. 08,
2014 Time: 11:00 a.m.
Dr. Ming,
doctor-in-charge, paid a visit to the patient. The patient was
69 years old now. Before she had a good health. She had a child
with normal childbirth. She had hypotension. 5 years ago the
vertigo and tinnitus began to attack her. But recently she had
dizziness, tinnitus, pains over her cervical spine and thoracic
vertebra, palpitations and insomnia. She felt sore all over her
body. There was no dry mouth. And her appetite was normal. The
color of urine was white. And her bowel movement was normal, but
a little soft. According to TCM diagnosis, Dr. Ming made the
treatment plans.
Date: Jun. 09,
2014 Time: 10:00 a.m.
The patient said
there is no obvious change. She still had dizziness and
tinnitus. And she refused to do the blood test.
Date: Jun. 10,
2014 Time: 10:00 a.m
The Blood pressure
went up to 118/60 mmHg. The vertigo and tinnitus were relieved.
And her palpitations were improved.
Date: Jun. 12,
2014 Time: 10:00 a.m.
The patient said
recently days she had no dizziness and tinnitus. Her pulse was
much smoother than before. But her sleep was not good.
Date: Jun. 17,
2014 Time: 10:00 a.m.
The patient said
her dizziness and tinnitus disappeared. And her sleep was
better. The pulse was smooth.
Date: Jun. 23,
2014 Time: 18:00 p.m.
The patient decided
to leave our hospital.
