2015, Adama Daff, came from Republic of Senegal, who suffered from Chronic kidney failure
On June. 14, 2015, Adama Daff, came from Republic of Senegal, who suffered from Chronic kidney failure. He had weakness for 2 years, accompanied with edema over his ankle joints for 2 months. He was hospitalized in our hospital. He got some improvement after 22 days TCM treatment.
Record of Hospitalization
Name: Adama Daff Sex: Male
Age: 59 Marital Status: Married
Nationality: Republic of Senegal Date of Admission: Jun. 14, 2015
Companion: Alone
First Medical Record
Date: June 16, 2015 Time: 9:00 a.m.
Adama Daff, male, 59 years old, had weakness for 2 years, accompanied with edema over his ankle joints for 2 months. The patient was hospitalized in our hospital with “Kidney Failure” for TCM treatment at 9:00 a.m. on June. 16, 2015.
Essential for Diagnosis:
1. The patient had suffered from weakness for 2 years. His ankle joints had edema for 2 months. 15 years ago the patient had history of hypertension. There was no medicine and food for him to get allergy response.
2. The patient felt fatigue. He was in bad spirit status. He was depressed. Occasionally he had shortness of breath, palpitation. His ankle joints had slight edema for 2 months. When the doctor pressed his muscle, it was sunken. There were no dizziness, headache, deafness, tinnitus, bitter and dry mouth. He preferred warm water, yet he controlled his water intake. His appetite was poor. There were stomachache and distension sensation. Sometimes he felt uncomfortable and fullness sensation over his abdomen. There were pains over his right toe-joints, accompanied with burning sensation. The same as his knee-joints and digital joints. There were no itching of his skin, night sweating and dysphoria in chestpalms-soles. His sleeping was good. His urination was OK, night urine was 1 to 2 times. The bowel movements were 2 to 3 times a day.
3. T: 36.4°C R: 20 times/minute P: 70 times/minute BP: 160/80mmHg
4. The patient had normal growth with fatty physique, sallow yellow facial expression, and chronic disease face. He cooperated with doctors when the physical examinations were made. There was no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. 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. And there is no enlargement over his thyroid and no congestion in his throat. There was no enlargement over his thyroid. His neck was soft without resistant. His trachea was symmetrical. The jugular vein was of no engorgement. His chest was symmetrical without deformity. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 70 times per minute. Heart rate was regular with no murmurs. His abdomen was soft with no pressing pains and rebound tenderness. There was no sign of deformity over his spine. The meningeal irritation sign was negative.The pathologic reflex of nervous system had not been drawn out. His tongue was light red with greasy, thick and yellow coating. His pulse was deep and string.
Diagnostic Differentiation:
TCM: Kidney turbidity
Western Medicine diagnosis:
1.Chronic renal failure
2. Hypertesion
3. Gouty
4. Cholecystitis and Renal Cyst
Treatment strategy and nursing:
1. Routine care of traditional Chinese internal medicine.
2. Grade Ⅱ care, taking low salt, low fat and low cholesterol diet.
3. Avoid wind-cold, regular daily life, have a good mood and take care of diet.
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: June 15, 2015 Time: 9:30 a.m.
Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient suffered from weakness for 2 years, and the ankle joints had edema for 2 months. Occasionally he had shortness of breath, palpitation. When the doctor pressed his muscle, it was sunken. There were no dizziness, headache, deafness, tinnitus, bitter and dry mouth. He preferred warm water, yet he controlled his water intake. His appetite was poor. There were stomachache and distension sensation. Sometimes he felt uncomfortable and fullness sensation over his abdomen. There were pains over his right toe-joints, accompanied with burning sensation. The same as his knee-joints and digital joints. There were no itching of his skin, night sweating and dysphoria in chestpalms-soles. His sleeping was good. His urination was OK, night urine was 1 to 2 times. The bowel movements were 2 to 3 times a day.
Date: Jun. 15, 2015 Time: 14:00 p.m.
The report showed that the WBC+1, PRO+1, IT +; HGB was 109G/L, HDL0.44L, TP43L, ALB29L, GLB14L, BU 23.88H, CRE-KU286H, CK228H, LDH 248H, A-AMY141H. The creatine was different from the reports of Shijiazhuang Kidney disease Hospital, so doctor suggested him to go to the superior hospital for re-checking.
Date: Jun. 16, 2015 Time: 10:30 a.m.
The vital signs of the patient were stable, there was no discomfort.
Date: Jun. 18, 2015 Time: 10:00 a.m.
The patient said he felt his spirit was better. And compared with before, the power increased. But his appetite was poor. His sleeping was normal. Night urination was one time. The bowel movement was 3 times a day. The edema of his lower limbs slightly relieved. Occasionally he had the pains over his right halluces. There was no dizziness, headache and vomiting. His blood pressure was 190/90mmHg. His tongue was red with yellow and thick coating. The pulse was string and deep. The report of examination from the superior hospital: TP55.7↓,ALB31.5↓,Na147.6↑, CL109.3↑, co2cp18.3↓, BUN 26.81↑, CREA665↑, UA527↑. Adjusted the formula today.
Date: Jun. 20, 2015 Time: 9:00 a.m.
The patient said his appetite was better obviously. The edema of his right leg obviously improved, yet it was still not good as the left one. His right halluces still had pains occasionally. His blood pressure was 170/90mmHg.
Date: Jun. 22, 2015 Time: 9:30 a.m.
The patient said his blood pressure was high, yet there was no dizziness and headache. The other symptoms were stable.
Date: Jun. 24, 2015 Time: 9:30 a.m.
The vital signs of the patient were stable. There was no unwell sensation.
Date: Jun. 26, 2015 Time: 9:30 a.m.
The patient said he was in good spirit status. His appetite was good. His blood pressure was 170/90mmHg. The report of examination from the superior hospital today: TP55.2↓, ALB30.8↓, CL110.0↑, co2cp16.2↓, BUN 25.23↑, CREA593.0↑, UA460↑.
Date: Jun. 28, 2015 Time: 9:30 a.m.
The patient said the tinnitus and the other symptoms were stable. The edema of right lower limb improved obviously. Today doctor adjusted his formula.
Date: July 01, 2015 Time: 9:30 a.m.
The patient said the tinnitus relieved, and the edema of lower limbs relieved greatly. His blood pressure was still slightly high.
Date: July 03, 2015 Time: 9:00 a.m.
The patient felt all his symptoms obviously relieved. Kept the same formula.
Date: July 03, 2015 Time: 9:00 a.m.
The report of examination from the superior hospital today: TP56.3↓,ALB31.8↓, BUN 23.95↑, CREA627.0↑, UA490↑.
Date: July 05, 2015 Time: 10:00 a.m.
The patient decided to leave our hospital. And he took the herbal tea for 2 months to consolidate the effect.