Brief Summary: On April 05, 2016, Mr. Pan Cunyue, from Zhongfang County near our hospital, who had been suffering from coughing and expectoration for more than 20 days, and accompanied with blood-stained sputum and pain all over for 7 days. 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. Pan Cunyue                                                      Sex: Male

Age: 79                                                                              Marital Status: Married

Nationality: China                                                              Date of Admission: April 05, 2016

Companion: Alone

                                                                                                   First Medical Record

Date: April 05, 2016                                    Time: 11:00 a.m.

This 79-year-old man had been suffering fromcoughing and expectoration for more than 20 days, and accompanied with blood-stained sputum and pain all over for 7 days. The patient was hospitalized in our hospital for TCM treatment as a patient with lung tumor at 11:00 a.m. on April 05, 2016.

Essential for Diagnosis:

1. The patient complained 20 days ago he caught a cold with cough, expectoration with blood. He did a CT check, he was diagnosed with metastatic tumor of lung. And he also suffered lumbar disc herniation. After the western medicine treatment, the symptoms relieved. In this week he got a cold again, the condition repeated attacked and becaming worse. He came to our hospital for TCM treatment. There was no history of TB and HB. And there was no history of drug or food allergy.

2. When the patient came to our hospital, he suffered coughing, expectoration with blood, chest pain and oppression, dizziness, headache and weakness. His appetite and sleeping were not good. There was pain over his joints and lower back. And there was stabbing pain over his right low back. He had bitter and dry mouth, while there was no tinnitus and sweating at night. Sometimes there was hot flash in his plams and soles. The color of his urine was yellow. His bowel movement was normal.

3. T: 36.8＜C     R: 20 times/minute    P: 80 times/minute     BP: 130/70mmHg

4. The patient grew normally. He was alert and cooperative. He had actue sick facial and flushing complexion. There was no sign of yellow sclera or yellowish skin, while there was slight 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. There was obvious pressing pain over his left shoulder joint. There were several follicles presented in his throat. It was slight red, yet there was no enlargement of his tonsil. His chest was symmetrical. Sound of breathing in the lungs was clear, without obfious 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 slight pressing pains over his, upper abdomen. There was no sign of deformity over his spine. There was obvious pressing pain over his thoracolumbar vertebraes. There was no obvious edema over his lower limbs. No pathological neuropathic positive.

Assistant Examination,

CT: 1. Metastatis Tumor of Lung;  2. Chronic Bronchtitis and Interstital Pneumonia; 3. Pleural Thickening;  4. Mediastinal Lymph Node Enlargement; 5. Thoracic Lumbar Degenerative Diseases.

Diagnostic Differentiation:

TCM: Heat and Pain Impediment, Masses.

Western Medicine diagnosis:

1. Tumor of lung

2. Lung infection

3. Tumor of Liver

4. Thoracic Lumbar Degenerative Diseases

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Å care. Slight diet, avoid wind-cold, regular daily life.

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

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

5. Acupuncture and massage: once a day

　

Date: April 06, 2016                                           Time: 9:00 a.m.

Dr. Shan, doctor-in-charge, paid a visit to the patient this morning. The patient complained 20 days ago he caught a cold with cough, expectoration with blood, chest pain and oppression, dizziness, headache and weakness. There was no obvious fever. His appetite and sleeping were not good. There was pain over his joints and lower back. And there was stabbing pain over his right low back. He had bitter and dry mouth, while there was no tinnitus and sweating at night. Sometimes there was hot flash in his plams and soles. The color of his urine was yellow. His bowel movement was normal. His tongue was red with yellow and thick coating. The pulse was rapid, slippery and string-like. According to the above condition, Doctor made the treatment strategy.

　

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

The vital signs of the patient were stable. The patient was in good spirit. The patient said the pain all over slightly relieved. Yet he still had bitter and dry mough. His appetite was still poor. He felt very tired. There was blood in his phlegm, the color was reddish. Checed up, the top of edge of his tongue body was red. And the tongue coating in the middle of tongue was yellow and thick. The pulse was weak. Doctor adjusted the formula.

　

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

The patient complained there was no obvious improvement. While the pain over his shoulder, back, lower back and four limbs relieved. And the phlegm still had the blood. To add some more herbs into the formula.

　

Date: April 09, 2016                                           Time: 9:00 a.m.

The patient the pain over his shoulder, back, lower back and four limbs obviously relieved. The hemoptysis was less, when he came to our hospital, it was more than 10 times a day, now it was 3 to 4 times a day. And the blood level in the phlegm obviously reduced. The bitter mouth was better. His sleeping was normal. And the tongue coating was thin and yellow. To adjust the formula.

　

Date: April 11, 2016                                            Time: 10:00 a.m.

The vital signs of the patient were stable. The patient said He still lost his appetite. And it still had phlegm with blood, yet the purulent blood secrection disappeared. The condition obviously improved.  

　

Date: April 15, 2016                                            Time: 10:00 a.m.

The patient said the chest oppression and short of breath improved. And the hemoptysis was less gradually. The pain all over his body almost disappeared. Continued the same formula.

　

Date: April 19, 2016                                            Time: 9:00 a.m.

The patient said his appetite was better. And there was no the feeling of fatigue now. The blood in the phlegh almost disappeared. Continued the formula.   

　

Date: April 21, 2016                                            Time: 9:00 a.m.

The vital signs of the patient were stable. The patient siad the symptoms and pains disappeared without relapse. The hemoptysis almost disappeared. The patient said his condition was stable and the symptoms almost recovered. He decided to leave the hospital today.