Brief Summary: On Jan. 13, 2015, Zhang Liangsheng, from the village of Jingping near our hospital, who suffered from dizziness and headache for 16 years. He was hospitalized in our hospital. He got some improvement after 14 days TCM treatment.

Record of Hospitalization

Name: Zhang Liangsheng                 Sex: Male

Age: 71                                              Marital Status: Married

Nationality: China                             Date of Admission: Jan. 13, 2015

Companion: Nobody

First Medical Record

Date: Jan. 13, 2015                Time: 15:00 p.m.

Zhang Liangsheng, male, 71 years old, had suffered from dizziness and headache for 16 years. His condition became severe for 3 days, accompanied with chest oppression and palpitations. The patient was hospitalized in our hospital as a patient with hypertension for TCM treatment at 11:00 a.m. on Jan. 13, 2015.

Essential for Diagnosis:

1. The patient said 16 years ago he had dizziness, headache, palpitations and shortness of breath because of overwork. And she went to the hospital, he was diagnosed with hypertension. Recent years, his repeated dizziness and headache attacked. He took some western medicines, his blood pressure was controlled. It was 160/90mmHg. 3 days ago, he had dizziness, headache, palpitations and oppression after work. He rested in bed and took the western medicine. His symptom relieved. The patient wanted TCM treatment. So he came to our hospital for TCM treatment. He also suffered from pains over his lower limbs and waist. There were no medicine and food for him to get allergy response.

2. When the patient came to our hospital, he had the following symptoms, such as dizziness, headache, oppression, palpitations and shortness of breath. He had pale complexion and cold four limbs. He also had lumbar pains, accompanied with numbness and pains over his lower limbs. There were pains over his right knee-joint. And the pains became severe after work. His spirit was normal. His sleep was not good. And his appetite was normal. He had frequent urination, especial at night, 6 times per night. The color of urine was clear. He had loose stool.

 3. T: 36.4°C   R: 21 times/minute    P: 61 times/minute   BP: 190/100mmHg

The patient had normal growth, physique and spiritual status, while with chronic disease face. There was no sign of yellow sclera or yellowish skin. There was no enlargement over his superficial lymph node. There were no sign of deformity and no masses over his five sense organs. The pupils were round and approximately equal in size. The pupillary reaction to the light was sensitive. There was no enlargement over his thyroid. There was no hyperaemia in his throat. His neck was soft without resistance stiffness. The jugular vein was of no engorgement. Sound of breathing in his lungs was clear without any rhonchi. Rhythm of his heart was 61 times per minute. Heart rate was regular. His abdomen was soft without pressing pains and rebound tenderness. There was no sign of deformity over his spine. He had soreness and pains of his waist, accompanied with numbness and pains over his lower limbs. There were pains over his right knee. The result of meningeal irritation sign was negative. The nerve pathological reaction was also negative. The tongue body was reddish with thin and white coating. The pulse was deep, wiry and slow.

4. Examination: complete the related examination