Brief Summary: On June 15, 2012, Ali, from Bahrain, who had suffered from dizziness and nausea for 9 years, back pains for 5 years and cough for one and half years, was hospitalized in our hospital. He had achieved great improvement after two and half months TCM treatment.

Record of Hospitalization

Name: Ali                                       Sex: Male

Age: 39                                          Marital Status: Unmarried

Nationality: Bahrain                        Date of Admission: June 15, 2012

Companion: Family                                      

First Medical Record

Date: Jun. 16, 2012                               Time: 10:00 a.m.

Ali, male, a 39-year-old man, had suffered from dizziness and nausea for 9 years, back pain for 5 years and cough for one and half years. He was hospitalized in our hospital for treatment at 7 p.m. on June 15, 2012.

Essential for Diagnosis:

1. The patient had suffered from dizziness and nausea for 9 years, back pains for 5 years and cough for one and half years.

2. When he came to our hospital, he had such symptoms as dizziness, chest depression, nausea, coughing with phlegm and occasional headache. He had hot pains over his lumbar. He was easy to be tired. Appetite was good. Sleep was normal. Bowel movement was two times per day. Urination was normal with yellowish color. He also had occasional diarrhea. He felt dryness in his mouth and liked drinking warm water. He suffered feeling of regurgitation one or two hours after meal.

3. T: 36.3°C   R: 20 times/minute    P: 80 times/minute   BP: 130/80mmHg

4. He grew normally with common nutrition and he was a little bit fat. His sense and speaking were normal. His mind was clear. He had chronic sick facial complexion. He suffered fist percussion over the kidneys. No edema was showed over her lower limbs and eyelids. His tongue was red and thin with teeth marks over the side of his tongue. His tongue coating was few. His pulse was deep, thready and weak.

Diagnostic Basis:

TCM: Phlegm turbidity of the patient affected the Yang-Qi, so he had dizziness. Damp phlegm blocking the middle-warmer, and the disharmony of the qi of the spleen and stomach caused chest depression, nausea and regurgitation after meal. Spleen, pertaining to earth was too powerful than the kidneys, which pertains to water, therefore, the symptom of lumbar pains appeared. According to the above analysis, his condition should be consumptive disease, due to phlegm turbidity blocking middle-warmer, yin-deficiency of kidneys and lungs.