Brief Summary: On March 23, 2016, Mr. Zeng Qingao, from Zhongfang County near our hospital, who had been suffering from distending and stuffy pain over his right ribs for 3 years, being severe for 3 months. It affected his appetite. He lost his appetite. He was hospitalized in our hospital. His condition got great improvement after 16 days TCM treatment with the help of Acupuncture, Herbal tea and Tuina in our hospital.

　

   Record of Hospitalization

Name: Mr. Zeng Qingao                                                                   Sex: Male

Age: 57                                                                                            Marital Status: Married

Nationality: China                                                                            Date of Admission: March 23, 2016

Companion: Alone

                                                                                                                    First Medical Record

Date: March 23, 2016                                    Time: 12:00 a.m.

This 57-year-old man had been suffering from distending and stuffy pain over his right ribs for 3 years, being severe for 3 months. The patient was hospitalized in our hospital for TCM treatment as a patient with hepatic cyst at 12:00 a.m. on March 23, 2016.

Essential for Diagnosis:

1. The patient complained 3 years ago there was fullness with discomfort over his hypochondrium without any inducement. And it caused to pain over his lower back, especially after meals. He did not care at the beginning, then he felt he lost his appetite day by day. Occasionally he had bitther mouth and he felt tired. His urination and bowel movement were abnormal. He often had constipation and the color of his urine was yellow. In April,2014 the patient took a B-ultrasound, it reported that he suffered from hepatic cyst, fatty liver and stone in his right kidney. He took the western medicine and combine with the Traditional Chinese Medicine, yet the effect was not obvious. And there was swelling pain over his shoulder-joints and his knee-joints. It affected the activity of his arms and legs. In Narch, 2016 he took a check, his UA was 485uml/l↑. He was diagnosed with gouty arthritis. He came to our hospital for TCM treatment.

2. When the patient came to our hospital, he suffered fullness with discomfort over his hypochondrium. And there was pain over his right low back, especially after meals, the pain became worse. He had copious urine, the color of urine was yellow. He lost his appetite and he had slight bitter mouth. He had constipation. There was obvious pain over his shoulder-joints and knee-joints with redness and hot sensation. The activity was limited.

3. T: 36.4°C     R: 20 times/minute    P: 80 times/minute     BP: 130/90mmHg

4. The patient grew normally. He was alert and cooperative. He had chronic sick facial and flushing complexion. There was no sign of yellow sclera or yellowish skin. There was no enlargement on the superficial lymph node of his whole body. Facial features were normal without masses and pressing pains. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. His ears were normal without secreta and pressing pain. His hearing was normal. His neck was soft without resistant, he could turn his neck flexibly. His windpipe appearance was good and in the center. There was distention of jugular vein. There was no enlargement on his thyroid gland. His chest was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 80 times per minute. Heart rate was regular with no murmurs. We did not hear any pathologic sound. His abdomen was soft with no pressing pains, rebound tenderness and enclosed mass. There was no sign of deformity over his spine. There was obvious distending pain over his shoulder and knee joints with slight hot. No pathological neuropathic positive. His tongue was slight red with yellow and thin coating. His pulse was rapid and string-like.

Diagnostic Differentiation:

TCM: Heat Impediment, Accumulate and kidney stone

Western Medicine diagnosis: 

1. Hepatic Cyst

2. Gouty Arthritis

3. Kidney Stone

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ care.

3. Slight diet, avoid wind-cold, regular daily life.

4. Completed the related examination, three routine inspection, the function of the kidneys and the liver, blood fat, blood sugar, anti-O, RF and IMX..

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

6. Acupuncture and massage: once a day

　

Date: March 23, 2016                                           Time: 12:00 a.m.

Dr. Luo, doctor-in-charge, paid a visit to the patient this morning. The patient complained 3 years ago there was fullness with discomfort over his hypochondrium without any inducement. And it caused to pain over his lower back, especially after meals. He did not care at the beginning, then he felt he lost his appetite day by day. Occasionally he had bitther mouth and he felt tired. His urination and bowel movement were abnormal. He often had constipation and the color of his urine was yellow. In April,2014 the patient took a B-ultrasound, it reported that he suffered from hepatic cyst, fatty liver and stone in his right kidney. He took the western medicine and combine with the Traditional Chinese Medicine, yet the effect was not obvious. And there was swelling pain over his shoulder-joints and his knee-joints. It affected the activity of his arms and legs. In Narch, 2016 he took a check, his UA was 485uml/l↑. His tongue was slight red with yellow and thin coating. His pulse was rapid and string-like. According to the above condition, Doctor Made the treatment strategy.

　

Date: March 24, 2016                                            Time: 10:00 a.m.

The patient said the condition was the same as last day, there is no obvious improvement.  

　

Date: March 25, 2016                                            Time: 10:00 a.m.

Test reports:

· HDL0.64mmol/l↓.  GLU8.0MMOL/L↑, TT-D2.45mmol/l. According to the reports, doctor adjusted his formula.

　

Date: March 30, 2016                                            Time: 10:00 a.m.

The patient said the symptoms improved. The pain over his right lower back relieved. The color of his urine became slight. His bowel movement was better. The swelling pain over his shoulder and knee joints relieved.

　

Date: April 3, 2016                                            Time: 10:00 a.m.

The vital signs of the patient were stable. The patient said the fullness with discomfort over his right ribs improved. His appetite was better.  

　

Date: April 07, 2016                                            Time: 9:00 a.m.

The patient said the fullness with discomfort over his right ribs disappeared. His appetite become better day by day. And the pains over his knee and shoulder joints disappeared completely. He can move flexibly. The color of urine was clear.  

　

Date: April 08, 2016                                            Time: 9:00 a.m.

The patient siad the symptoms and pains disappeared. And his appetite was normal. The patient decided to leave the hospital today.