Brief Summary: On April 25, 2013, Mr. Pan, from the town of Luting’ao, who had been suffering neck pains for more than six years, accompanied with headache and dizziness for 2 years and being severe for more than half a year, was hospitalized in our hospital. He achieved great improvement after nearly 16 days TCM treatment with the help of Acupuncture, Herbal tea and Tuina in our hospital.

Record of Hospitalization

Name: Mr. Pan                                  Sex: Male

Age: 55                                             Marital Status: Married

Nationality: China                            Date of Admission: Apr. 25, 2013

Companion: Alone

First Medical Record

Date: April. 25, 2013                                Time: 11:00 a.m.

This 55-year-old man had been suffering from neck pains for six years. He suffered headache and dizziness for about 2 years. His condition became severe for half a month. The patient was hospitalized in our hospital for TCM treatment at 16:00 p.m. on April 25, 2013.

Essential for Diagnosis:

1. The patient had been suffering from pains over his neck for six years. He suffered headache and dizziness for about 2 years. His condition became severe for half a month.

2. The patient complained that he suffered neck pains, and when pains happened, he liked to press the painful part. Headache and dizziness mostly occurred over both sides of his head. He liked to vomit when headache happened. He had blurred vision and dryness in his eyes. He felt tired. He also felt chest depression. He felt dryness in his mouth and liked to drink hot water. He was afraid of coldness. His appetite was good. Sleep was normal. Bowel movement and urination were normal.

3. T: 36.5°C   R: 24 times/minute    P: 96 times/minute   BP: 160/106mmHg

4. The patient grew normally with standard body shape. He was alert and cooperative. He had florid facies. There were no sign of yellow sclera or yellowish skin. There was no enlargement on the superficial lymph node of his whole body. Facial features were normal. His neck was soft and there were obvious pressing pains over his neck. There was no enlargement on his thyroid gland. Rhythm of his heart was 96 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. We did not hear any pathologic sound. His abdomen was soft with no pressing pains, rebound tenderness and enclosed mass.

Diagnostic Differentiation:

TCM:

The patient suffered neck pains for six years and headache and dizziness for 2 years, which belonged to the category of impediment and dizziness of TCM. Because the factor of the patient’s occupation, he kept a poor posture for long time, which caused stagnant movement of qi and blood over his neck part and stagnation of the channels. When the channels were blocked, pains happened. A long illness wasted too much vital qithen the symptom of deficiency of qi and blood appeared. The qi and blood could not nourish the channels, so he liked to press the painful points when pains happened. If long illness caused deficiency of the kidneys and liver, and led to disharmony of yin and yang, it would disturb the upper head and eyes and cause headache and dizziness. According to the theory of TCM, his symptom could be diagnosed as impediment syndrome, which was due to the deficiency of the liver and kidneys. His symptom also could be diagnosed as dizziness, which was due to the deficiency of the liver and kidneys and deficiency-yang. Treatment strategy should be calming the liver and suppressing yang, as well as nourishing the liver and kidneys.