2013, Sophie, from Israel, who had been suffering from repeated dizziness for 5 years
On September 23, 2013, Sophie, from Israel, who had been suffering from repeated dizziness for 5 years, accompanied by blurred vision and vomiting, was hospitalized in our hospital. She achieved great improvement after three months TCM treatment with the help of herbal tea, acupuncture and massage.
Record of Hospitalization Name: Sophie Sex: Female Age: 50 Marital Status: Married Nationality: Israeli Date of Admission: September 23, 2013 Companion: Her husband First Medical Record Date: Sep. 23, 2013 Time: 12:00 a. m. This 50-year-old lady had been suffering from repeated dizzness for 5 years, accompanied by blureed vision and vomiting. The patient was hospitalized in our hospital for TCM treatment at 12 a.m. on September 23, 2013. Essential for Diagnosis: 1. The patient had been suffering repeated dizziness for 5 years, accompanied by blurred vision and vomiting, and seeing things rotating. 17 years ago, she suffered a car accident, and her cervical vertebrae were injured. There were pains over her cervical vertebra. Right now, there were pains over the right side over her neck. She has the medical history of asthma, and when she caught cold, asthma happened. 2. When she came to our hospital, she suffered dizziness, blurred vision, seeing things rotating, nausea and vomiting. Her conditions happened repeatedly, sometimes several minutes, sometimes 6-7 days. When she turned her neck, the above symptoms happened. She felt puffy eyes. Sometimes she suffered shortness of breath, tinnitus and cough. She had night urinations for 2-3 times every night. She was afraid of cold. Bowel movement was normal. The feeling over her lower abdomen almost went away. There were numbness and pains over her lumbar part. 3. T: 36.3°C R: 20 times/minute P: 80 times/minute BP: 110/80mmHg 5. The patient grew normally with a little fat body figure. Her spiritual activity was good. There were several pressing pain points over her body. Her tongue was red with white and thin coating. There were teeth marks over her tongue. Her pulse was deep, thready and slightly slippery. Diagnostic Basis and Differentiation:
TCM: The patient had suffered from dizziness, blurred vision, rotating views, vomiting for 5 years. She also suffered shortness of breath, tinnitus and uncontrollable urination, afraid of cold, back pains. Her tongue was red with white and thick tongue coating. There were teeth marks on her tongue edges. Her pulse was deep, thready and slightly slippery. Her condition belongs to the category of vertigo in TCM. She also had the medical history of asthma. Turbid phlegm and wind phlegm attack upwards the orifices, and then vertigo problem occurred. Stagnation of turbid phlegm in middle-warmer and disharmony of the ascending and descending function of the qi of spleen and stomach caused nausea and vomiting. The patient was slightly old and the kidney-yang was sufficiency, then the symptoms of back pains, aversion to cold, tinnitus, uncontrollable urination occurred. Therefore, her condition should be vertigo, due to stagnation of turbid phlegm in middle-warmer and yang deficiency of the spleen and kidneys.
Western Medicine:
1. Dizziness, seeing things rotating and vomiting for 5 years.
2. Turning her neck too fast, her symptoms occurred. Puffy eyes, shortness of breath, tinnitus, uncontrollable urination.
First Diagnosis:
TCM: Vertigo. Symptom identification: stagnation of turbid phlegm in middle-warmer and yang deficiency of spleen and kidneys.
Western medicine: Ménière's Disease
Treatment strategy and nursing:
1. Routine care of traditional Chinese internal medicine.
2. Grade Ⅱ care.
3. Pathogenesis: stagnation of turbid phlegm in middle-warmer and yang deficiency of spleen and kidneys. 4. TCM strategy: removing dampness and phlegm, warming the kidney-yang. 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: Sep. 23, 2013 Time: 12:00 a. m.
Dr. Zhu Ming, doctor paid a visit to the patient. The patient complained that she suffered dizziness, blurred vision, rotating views, vomiting for 5 years. She also suffered shortness of breath, tinnitus, and uncontrollable urination, aversion to cold, back pains. Her tongue was red with whitish and thick coating. There were teeth marks over her tongue surface. Her pulse was deep, thready and slightly slippery. Turbid phlegm and wind phlegm attack upwards the orifices, and then vertigo problem occurred. Stagnation of turbid phlegm in middle-warmer and disharmony of the ascending and descending function of the qi of spleen and stomach caused nausea and vomiting. The patient was slightly old and the kidney-yang was sufficiency, then the symptoms of back pains, afraid of cold, tinnitus, uncontrollable urination occurred. According to the theory of TCM, her condition should be vertigo, due to stagnation of turbid phlegm in middle-warmer and yang deficiency of spleen and kidneys. The treatment for her condition was to remove dampness and phlegm, as well as to warm the kidney-yang.
Date: Sep. 24, 2013 Time: 10:00 a. m. There were no obvious change about her bowel movement and urination. Date: Sep. 25, 2013 Time: 10:00 a. m.
The patient said he felt better over her back movement.
Date: Sep. 26, 2013 Time: 10:00 a. m.
The patient said she felt slightly dizziness. Urine was clearer than before, but no obvious change about her bowel movement. Date: Sep. 27, 2013 Time: 10:00 a. m. The patient said dizzness and headache were improved a lot. Urine was clearer than before, but no obvious change about her bowel movement. Sleep was good. Date: Sep. 30, 2013 Time: 10:00 a. m. The patient said appetite and sleep were normal. Her weight decreased 1KG. Urination and bowel movement were normal. Spirit was better. Date: Oct. 3, 2013 Time: 10:00 a. m. The patient said she suffered diarrhea yesterday.
Date: Oct. 5, 2013 Time: 10:00 a. m.
The patient still suffered diarrhea, but without headache or dizziness. Her pulse was still deep and thready.
Date: Oct. 8, 2013 Time: 10:00 a. m.
The patient, today, still suffered slight diarrhea.
Date: Oct. 11, 2013 Time: 10:00 a. m.
Diarrhea stopped. There was no obvious change over her weight. The distension feeling over her stomach decreased somewhat. The heavy feeling over her lower limbs was reduced. Date: Oct. 14, 2013 Time: 10:00 a. m. The patient felt more lightness over her hands and legs, less heavy sensation than before. There was no obvious discomfort over her body. There were no dizziness and tinnitus. Her sleep and appetite were good. She has stopped use of female hormone. The prescription was still to tonify the kidneys and spleen as well as to soothe the liver and improve the circulation of the qi. Date: Oct. 18, 2013 Time: 10:00 a. m. She had slight constipation. She felt tired over her hands and feet. Distension appeared on her abdomen part. Her pulse was deep and thready. She did not suffer dizziness and headache. There was not much urine. Date: Oct. 22, 2013 Time: 10:00 a. m. She had slight constipation. She did not feel obvious distension over her abdomen. Her pulse was float and wiry. Date: Oct. 26, 2013 Time: 10:00 a. m. Headache went away. The patient said from this month on, she had whites. Appetite and sleep were normal. Pains over her shoulders were alleviated. Her pulse was deep and thready. Date: Nov. 6, 2013 Time: 10:00 a. m. The patient did not catch cold or suffer dizziness, but there still were tense feeling over her neck and shoulders. Appetite was a little down than before. Her sleep was good. She had stopped the use of female sex hormone for almost one month. She did not feel any discomfort. Date: Nov. 10, 2013 Time: 10:00 a. m. Today, the patient came with the period. She did not feel any headache, dizziness, or abdominal pains. Date: Nov. 14, 2013 Time: 10:00 a. m. The period of the patient stopped. She did not feel any discomfort. The prescription was still to reduce phlegm and tonify spleen as well as to free the circulation of blood and remove stasis of blood. Date: Nov. 17, 2013 Time: 10:00 a. m. The patient did not feel headache. She still felt tense feeling over her back and lumbar part. Date: Nov. 22, 2013 Time: 10:00 a. m. The patient did not feel headache or any discomfort. No more tense feeling over her back and lumbar part. Date: Nov. 26, 2013 Time: 10:00 a. m. Appetite of the patient was increased. Her pulse was deep and thready. No more pains over her shoulders. Date: Nov. 30, 2013 Time: 10:00 a. m. The patient did not feel headache. Her appetite and sleep were normal. There was no obvious discomfort. Date: Dec. 5, 2013 Time: 10:00 a. m. The patient did not feel any discomfort. She still felt about her obesity problem. She did not feel headache and dizziness for long time since the treatment started. Date: Dec. 12, 2013 Time: 10:00 a. m. The patient was in the time of her period. She felt headache last night. Her pulse was weak, especially her liver pulse. Date: Dec. 16, 2013 Time: 10:00 a. m. Days before, the patient had period. She only suffered headache. After taking some herbal tea, pains disappeared. Her pulse was still wiry. Date: Dec. 20, 2013 Time: 10:00 a. m. The patient only suffered watery bowel movement. She had no more headache and insomnia.
Date: Dec. 25, 2013 Time: 17:00 p. m.
The patient decided to leave our hospital today. After TCM treatment for more than 3 month, her symptoms almost got cured. She was satisfied with our TCM service. And she decide took some medicine back to continue the treatment.