Mr. Khalil, from Bahrain, had been suffering from hypertension
Mr. Khalil, from Bahrain, had been suffering from hypertension for more than 25 years and in rent years he suffered from diabetes. At present, the patient complained of weakness over his general body and severe night urination problem. He was hospitalized in our hospital on April 6, 2011 for TCM treatment. He achieved great improvement in his condition after one month TCM treatment with the help of herbal tea, acupuncture, massage etc.
Record of Hospitalization Name: Khalil Sex: Male Age: 60 Marital Status: Unmarried Nationality: Bahraini Date of Admission: Apr. 6, 2011 Companion: Family First Medical Record Date: Apr. 7, 2011 Time: 10:00 am This 60-year-old gentleman had been suffering from hypertension for more than 25 years and in recent years he suffered from diabetes. At present, the patient complained of weakness over his general body and severe night urination problem. The patient was hospitalized in our hospital for TCM treatment at 19:00 am on Apr. 6, 2011. Essential for Diagnosis: 1. The patient had been suffering from weakness over his whole general body. He had abnormal urine of 8-10 times per day, and his night urination was 3-4 times. He had edema over his lower limbs, especially over the joints of his ankles. 2. The patient was attacked by hypertension 25 years ago, and at that time, it was not very severe. Later on, he took some western medicines for his hypertension. His blood rate sometimes was high, and sometimes low. It was very unstable. In recent years, he suffered from diabetes. Years ago, he sometimes had headaches, after took the anti-hypertension medicines, the symptom of headache disappeared. 3. When the patient was hospitalized in our hospital, he had heavy nasal blocking, easily-catching cold and loss of smell, with occasional coughing. He did not have phlegm. His nasal mucosa showed hyperemia and edema. The lymph gland in his throat was two degrees enlargement. The lymph follicle was swelling evidently. He did not suffer from fever. His pulse was floating. His tongue coating was thin and yellow. 4. T: 36.4°C R: 20 times/minute P: 80 times/minute 5. His spirit activity was good. He grew normally. His diet was of common nutrition. He had fine sense. The motion of his four limbs was flexible. He had gray facial complexion with a slightly plump body. His jugular reflux was slightly positive. Sound of breathing in the lungs was clear, without any rhonchi. The formation and size of his thorax were normal. His abdomen was soft. There was no enlargement of his liver and spleen. There were no abdominal jugular reflux sign and Murphy’s sign.
6. His four limbs were soft without any limitation of movement, but there was edema in his lower limbs, in particular the joints of his ankles.
Diagnostic Basis:
TCM: The patient suffered from weakness over his whole body. His urination was abnormal with night urination of 3-4 times. There was edema in his lower limbs, in particular the joints of his ankles. His blood sugar was little high with the blood pressure of 174/90. His pulse was wiry. His tongue was slightly red with yellow and greasy tongue coating. So, his condition could be diagnosed as edema. Western Medicine: The patient suffered from weakness over his whole body. His urination was abnormal with night urination of 3-4 times. There was edema in his lower limbs, in particular the joints of his ankles. His blood sugar was little high with the blood rate of 174/90. His pulse was wiry. His tongue was slightly red with yellow and greasy tongue coating. So, his condition could be diagnosed hypertensive nephropathy. Diagnostic Differentiation: TCM: The patient’s condition should be differentiated with distension. As to the symptoms of edema, there usually appear swellings on patient’s face, head, eyelids, limbs, abdomen and back, or even dropsy on the patient’s whole general body. Patient with severe edema may suffer from ascites and hydrothorax. While ascites is the main symptom of distention and when it becomes worse, swelling also could appear on limbs or even the whole body. The swelling of Khalil’s case only happened on his feet and legs without any shifting dullness in his abdomen. Abdominal distension was not very severe. Therefore, it was easy to differentiate them. Western Medicine: His condition should be differentiated from the rheumatic heart disease edema. As to the rheumatic heart disease edema, there exist pains on the joints of the body. The positive rheumatic factors help to make differentiations. So, it was easy to differentiate them. First Diagnosis: TCM: Edema. Symptom identification: the insufficiency of the liver and kidney, the qi vacuity and blood staisis. Western Medicine: hypertensive nephropathy. Treatment strategy and nursing: 1. Routine care of traditional Chinese internal medicine. 2. Grade Ⅱ care. 3. Companion. 4. Diet of low salt and low fat. 5. Pathogenesis: the insufficiency of the liver and kidney, the qi vacuity and blood stasis. 6. TCM strategy: promoting the circulation of blood and transforming stasis, nourishing the liver and kidney. 7. Herbal tea: one dosage a day and drink twice 8. Acupuncture and massage: once a day 9. Have more medical examination if necessary. Date: Apr. 7, 2011 Time: 10:00 am This morning, Professor Yang Qingzhi paid a visit to the patient. The patient complained of weakness over his whole body. His urination was abnormal with night urination of 3-4 times. There was edema in his lower limbs, in particular the joints of his ankles. His blood sugar was little high with the blood pressure of 170/90. His pulse was wiry. His tongue was slightly red with yellow and greasy tongue coating. Professor Yang thought, according to the symptoms of the tongue and pulse, the patient’s condition was caused by the insufficiency of the liver and kidneys, the qi vacuity and blood stasis. Therefore, the treatment should be promoting the circulation of blood and transforming stasis, nourishing the liver and kidneys. Date: Apr. 10, 2011 Time: 10:00 am The patient said edema over his lower limbs was reduced a lot. There were wrinkles over the skin on his lower limbs. Date: Apr. 15, 2011 Time: 10:00 am
The patient said edema of his lower limbs disappeared and the wrinkles of the skin were normal now. His pulse was wiry. His tongue was slightly red with yellow tongue coating.
Date: Apr. 20, 2011 Time: 10:00 am
The patient had high spirit these days. Sleep was good. There was no edema any more. The blood pressure was 170/90. His pulse was a little bit wiry. His tongue was of light red with slightly tongue coating. Date: Apr. 23, 2011 Time: 10:00 am The patient’s blood pressure still was 170/90. Other conditions were stable. His tongue coating was slightly yellow. His pulse was slight wiry, and his tongue was slightly red. Date: Apr. 27, 2011 Time: 10:00 am
The patient today felt fatigued, due to the cold he caught recently. He coughed with white phlegm. Sleep was not good. His tongue coating was white. His pulse was a little bit floating. His tongue body was slightly red.
Date: Apr. 30, 2011 Time: 10:00 am
The patient got recovered from cold without the sense of fatigue. His blood pressure was now 160/80. His spirit and appetite were good. Date: May 3, 2011 Time: 10:00 am His blood pressure today was 170/90. Spirit and appetite were good. Sleep in the recent days was good. His tongue was slightly red with slightly white tongue coating. His pulse was a little bit wiry. Date: May 6, 2011 Time: 10:00 am Khalil’s condition improved greatly than he came to our hospital. The patient decided to leave the hospital today. After TCM treatment in our hospital for 31 days, he had recovered from edema. He no longer felt weak. His urinary problem was improved a lot. Now his did not have night urination any more. His problem of urinary endless was improved a lot. Doctor’s advice after leaving hospital: 1. Avoid wind-cold, take care of cold. 2. Take herbal medicine back for continuing treatment.