Brief Summary: On Mar. 06, 2015, Yin Taoyu, came from Zhongfang County, who had been suffering from dizziness, soreness of her neck for more than 10 years and being severe for 5 days. She was hospitalized in our hospital. The dizziness was recovered completely and she achieved some improvement on her sore neck after 11 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization

Name: Yin Taoyu                          Sex: Female

Age: 46                                         Marital Status: Married

Nationality: China                        Date of Admission: Mar. 06, 2015

Companion: Alone

First Medical Record

Date: Jan. 10, 2015                    Time: 11:00 a.m.

This 46-year-old woman had been suffering from dizziness and soreness over her neck for more than 10 years and being severe for 5 days. He was hospitalized in our hospital as a patient with Meniere’s disease for TCM treatment at 13:00 p.m. on Mar. 06, 2015.

Essential for Diagnosis:

1. The patient had been suffering dizziness and soreness over her neck for more than 10 years and being severe for 5 days. The course of her disease was long. There was no injury history. And there was no allergy history of any medicine or food.

2. When the patient came to our hospital, she had the following symptoms, such as dizziness, nausea, tinnitus, weakness and soreness over her neck. And it was difficult to turn her neck. There was numbness over her shoulders and upper limbs. There were soreness and weakness of her waist and knees, dryness of eyes and blurred vision. Her stool was shapeless. Her urine was normal.

3. T: 36.5°C   R: 18 times/minute    P: 60 times/minute   BP: 120/70 mmHg

The patient had normal spiritual status with chronic painful facial expression. There was no yellow skin or yellow sclera over her whole body. There was no enlargement over her lymph node. Her neck was stiff, and it 借机difficult to turn her neck. There were obvious pressing pains around her neck and shoulders. She could not move her left arm. Her five sense organs were normal. There was no enlargement over her thyroid. The appearance of her trachea was good, in the center. The jugular vein was of no engorgement. Her chest was symmetrical. Sound of breathing in the lungs was clear with no rhonchi. Rhythm of her heart was 60 times per minute. Heart rate was regular with no murmurs. Her abdomen was soft with no pressing pains and enclosed masses. Murphy’s sign was negative.  There was no deformity over her spine and four limbs. The nerve pathologic reflex was not found. The tongue body was slightly white with thin and white coating. The edge of her tongue had obvious teeth marks. The pulse was wiry and weak.

4. Examination: completed the related examination.