Brief Summary: On April 27, 2015, Mr. Zhou Jianping, from Zhongfang County near our hospital, who had been suffering from headache and dizziness for more than 8 years, being severe for 5 days. He was hospitalized in our hospital. His condition got great improvement after 16 days TCM treatment with the help of Acupuncture, Herbal tea and Tuina in our hospital.

Record of Hospitalization

Name: Mr. Zhou                           Sex: Male

Age: 40                                        Marital Status: Married

Nationality: China                       Date of Admission: April 27, 2015

Companion: Alone

First Medical Record

Date: March. 26, 2015                 Time: 11:00 a.m.

This 62-year-old man had been suffering from repeated joint-pains over his lower limbs for more than 4 years, being severe for half month. The patient was hospitalized in our hospital for TCM treatment as a patient with gouty arthritis at 10:00 a.m. on March 26, 2015.

Essential for Diagnosis:

1. The patient had been suffering from repeated joint-pains over his lower limbs for more than 4 years, being severe for half month. He had no allergy history of any medicine or any food.

2. When the patient came to our hospital, he suffered the redness and swelling of knee-joits and foot thumb joints, accompanied with burning pains, especially his knee-joints. He could not stand and walk for a long time. The function of stretching and bending his joints was limited, yet it was not related with the weather changes. Sometimes he had dizziness and tinnitus, decreased hearing and soreness and weakness of his waist. His appetite and sleeping were good. And the urination and bowel movement were normal.

3. T: 36.5°C     R: 20 times/minute    P: 88 times/minute     BP: 150/90mmHg

4. The patient grew normally. He was alert and cooperative. He had chronic sick facial and flushing complexion. He was in compulsive position. There was no sign of yellow sclera or yellowish skin. There was no enlargement on the superficial lymph node of his whole body. His neck was soft without resistant, he could turn his neck flexibly. His windpipe appearance was good and in the center. There was slight distention of jugular vein. There was no enlargement on his thyroid gland. His chest was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 88 times per minute. Heart rate was regular with no murmurs. We did not hear any pathologic sound. His abdomen was soft with no pressing pains, rebound tenderness and enclosed mass. There was no sign of deformity over his spine. There was no obvious pressing pains around his lumbar vertebra. The knee-joints of his lower limbs was obviously red and swell with pressing pains. There was large swelling of his foot thumbs. The function of stretching and bending over his knee-joints was limited. No pathological neuropathic positive. His tongue was dark red with yellow coating. His pulse was deep, rapid and unsmooth.

Diagnostic Differentiation:

TCM: Pains Impediment

Western Medicine diagnosis:  Gouty arthritis

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ care.

3. Diet of low salt and low fat. Monitoring the blood pressure, once a day.