2012, Ali, from Bahrain, who had suffered from dizziness and nausea for 9 years
Record of Hospitalization Name: Ali Sex: Male Age: 39 Marital Status: Unmarried Nationality: Bahrain Date of Admission: June 15, 2012 Companion: Family First Medical Record Date: Jun. 16, 2012 Time: 10:00 a.m. Ali, male, a 39-year-old man, had suffered from dizziness and nausea for 9 years, back pain for 5 years and cough for one and half years. He was hospitalized in our hospital for treatment at 7 p.m. on June 15, 2012. Essential for Diagnosis: 1. The patient had suffered from dizziness and nausea for 9 years, back pains for 5 years and cough for one and half years. 2. When he came to our hospital, he had such symptoms as dizziness, chest depression, nausea, coughing with phlegm and occasional headache. He had hot pains over his lumbar. He was easy to be tired. Appetite was good. Sleep was normal. Bowel movement was two times per day. Urination was normal with yellowish color. He also had occasional diarrhea. He felt dryness in his mouth and liked drinking warm water. He suffered feeling of regurgitation one or two hours after meal. 3. T: 36.3°C R: 20 times/minute P: 80 times/minute BP: 130/80mmHg 4. He grew normally with common nutrition and he was a little bit fat. His sense and speaking were normal. His mind was clear. He had chronic sick facial complexion. He suffered fist percussion over the kidneys. No edema was showed over her lower limbs and eyelids. His tongue was red and thin with teeth marks over the side of his tongue. His tongue coating was few. His pulse was deep, thready and weak. Diagnostic Basis: TCM: Phlegm turbidity of the patient affected the Yang-Qi, so he had dizziness. Damp phlegm blocking the middle-warmer, and the disharmony of the qi of the spleen and stomach caused chest depression, nausea and regurgitation after meal. Spleen, pertaining to earth was too powerful than the kidneys, which pertains to water, therefore, the symptom of lumbar pains appeared. According to the above analysis, his condition should be consumptive disease, due to phlegm turbidity blocking middle-warmer, yin-deficiency of kidneys and lungs. Western Medicine: The patient had suffered from dizziness, nausea and lumbar pains for 5 years and cough for one and half years. He had fat body figure, fist percussion over the kidneys and no edema over his lower limbs. He also had some exact examinations at local hospital of his country. First Diagnosis: TCM: Consumptive disease Symptom identification: Phlegm turbidity blocking the middle-warmer, deficiency of the kidneys and lungs Western medicine diagnosis: chronic renal failure Treatment strategy and nursing: 1. Routine care of traditional Chinese internal medicine. 2. Grade Ⅱ care. 3. Common diet 4. TCM strategy: resolve 5. Herbal tea: one dosage a day and drink twice 6. Acupuncture and massage: once a day 7. Have more medical examination if necessary. Date: Jun. 17, 2012 Time: 9:00 a.m. Dr. Ming paid a visit to this patient this morning. The patient complained that he suffered dizziness and nausea for 9 years, lumbar pains for 5 years and cough for one and half years. He had heat feeling over his lumbar pain area. He suffered feeling of regurgitation one or two hours after meal. He felt dryness in his mouth and liked to drink warm water. There were pressing pains over his lumbar part. No edema was presented over his lower limbs and face. His tongue was red and thin with few coating. There were teeth marks over his tongue sides. Her pulse was deep, thready and weak. According to the theory of TCM, Dr. Ming thought that the patient’s condition should be consumptive disease, due to phlegm turbidity blocking the middle-warmer as well as deficiency of the kidneys and lungs. Date: Jun. 21, 2012 Time: 9:00 a.m. The patient complained dizziness and headache. He suffered heat pains over the first metatarsal bone of his left body side. Nausea and cough turned better. Lumbar pains were reduced somewhat. Manifestation of his tongue and pulse was the same as before. Date: Jun. 24, 2012 Time: 9:00 a.m. The patient complained that he still suffered from dizziness, headache and nausea. His tongue was red and thin, with few tongue coating. Teeth marks were presented over the edges of his tongue. Her pulse was deep, thready and weak. Date: Jun. 28, 2012 Time: 9:00 a.m. Date: Jul. 1, 2012 Time: 9:00 a.m. No more pains over the patient’s feet. Date: Jul. 4, 2012 Time: 9:00 a.m. The patient felt no more pains over his feet. He still had coughing and abdominal distension. He had no bowel movement for three days. His tongue was red and thin, with few tongue coating. Teeth marks were presented over the edges of his tongue. Her pulse was deep, thready and weak. Date: Jul. 8, 2012 Time: 9:00 a.m. The patient said he already had bowel movement, but he was still suffering coughing, with yellowish or whitish phlegm. Running nose was better. His tongue was red with few coating. Teeth marks still presented. His pulse was thready. Date: Jul. 12, 2012 Time: 9:00 a.m. The patient complained he was still suffering coughing, with yellowish or whitish phlegm. No more running nose. He still suffered dry nausea. Manifestation of tongue and pulse was the same as before. Date: Jul. 15, 2012 Time: 9:00 a.m. The patient complained that when he coughed, the phlegm was sticky and yellowish, and he felt chest pains. He suffered pains over his kidney areas. Date: Jul. 18, 2012 Time: 9:00 a.m. Cough and chest pains were better than days before. Pains over his kidney areas were reduced. Date: Jul. 25, 2012 Time: 9:00 a.m. The patient complained that his right ankle joint was painful and hot. He also felt slightly pains over his lumbar. His tongue was red with few coating and teeth marks. His pulse was deep wiry and rapid. Date: Jul. 28, 2012 Time: 9:00 a.m. Ankle joint pains were reduced a lot. Slight pains happened over his lumbar part. Manifestation of his tongue and pulse was the sa.m.e as before. Date: Aug. 1, 2012 Time: 9:00 a.m. The patient said there were no more pains over his ankle joint, but still slight pains over his back. His tongue was red with few coating and teeth marks. His pulse was deep and thready. Date: Aug. 5, 2012 Time: 9:00 a.m. Asked him to do the following exa.m.inations: blood routine and urine routine, liver and kidney functions, B ultrasound over his kidneys. Date: Aug. 11, 2012 Time: 9:00 a.m. The patient had no more symptoms of nausea, regurgitation and dizziness, but slight cough with whitish phlegm. He still suffered back pains. Date: Aug. 15, 2012 Time: 9:00 a.m. The patient still suffered from slight cough, but expectoration was better. Date: Aug. 18, 2012 Time: 9:00 a.m. The patient did not have cough now, but felt some bit of phlegm in his throat. There were no more dizziness, nausea and vomiting. Slight pains still showed over his back. Date: Aug. 24, 2012 Time: 9:00 a.m. The patient complained that his condition was the sa.m.e as days before. Date: Aug. 26 2012 Time: 9:00 a.m.
Exa.m.ination report: Blood-R: RBC 3.46*1012/L; HGB 90g/L. Urine-R: urine protein +++; hyperglobulinemia 1.3g/L; A/G 0.99; BUN 19.7% umol/L; Creatinine 277umol/L; UA 481umol/L; Red blood cells and HGB were higher than last exa.m.ination. Serum creatinine and UA were lower than last test. The patient had no more dizziness, headache, nausea and vomiting. He still had slight back pains and less phlegm in his throat.
Date: Aug. 31 2012 Time: 9:00 a.m.
The patient said that there were no more dizziness, nausea and lumbar pains. There still was little phlegm in his throat. He felt slight pains below his right scapula. The conclusion of his test report: there was still urine protein +++, but no urine occult blood. Blood urea nitrogen was 0.7 umol/L higher than before. Serum creatinine was decreased by 96 umol/L. Blood uric acid was decreased by 134 umol/L. Kidney function of the patient had been improved a lot. Most of his western medicine had been stopped. At present, his blood pressure was normal. Mr. Ali asked to leave our hospital. He would take some herbs back home for continuing treatment. The doctor asked him to take enough rest and to take regular checks.