Name: Mhlonishwa                                                                                                Sex: Male

Age: 13                                                                                                                  Marital Status: Unmarried

Nationality: Swazi                                                                                                  Date of Admission: May 12, 2011

Companion: His Mother

First Medical Record

Date: May. 12, 2011                                      Time: 10:00 am

Mhlonishwa, 13-year-old body, had been suffering from deafness of his both ears for 13 years. The patient was hospitalized in our hospital for TCM treatment at 19:00 am on May 12, 2011.

Essential for Diagnosis:

1. The patient had been suffering from deafness of his both years for 13 years.

2. The patient lost his hearing of both ears when he was only six months old without any clear reasons; while he was born with normal good hearing. At the age of six months, his hearing became abnormal, and at that time, he could only hear loud sound. When he was one year old, he lost hearing completely. His mother said when the patient took a kind of medicine introduced by other people for enhancing physical fitness and wisdom. When they noticed his abnormal hearing, the patient was given a kind of medicine named SIX BOTTLES. His mother thought his loss of hearing might be caused by overdose of the medicine. When he was eight years old, doctor in South Africa did some tests for him so as to make a cochlear implantation for him. But the test results presented that there were some holes in his internal ear. The holes might be ulcers. Therefore, he did not take the implantation.

3. When the patient was hospitalized in our hospital, he could not hear anything. He could understand some lip readings. His spirit was good. There were no restrictions with his movement. There was ulcer in his mouth. There were little red papules on his tongue. He liked to drink cold water. He was easy to catch cold. Urine was yellowish. Stool was soft. Pulse of his right hand was powerful and rapid, while left thready and rapid.

4. T: 36.3¡ăC   R: 20 times/minute    P: 82 times/minute  

5. His spirit activity was good. He grew normally. His diet was of common nutrition. He had fine sense. The lymph gland in the back of his ear was slightly swelling. There was no distention of jugular vein. His abdomen was normal, and it was soft when pressed. There was no enlargement on his liver and spleen. His four limbs grew normally. Sound of breathing in the lungs was clear, without any rhonchi. The formation and size of his thorax were normal. There was no enlargement in his heart. His heart rhythm was normal with no murmurs. There was no enlargement with his kidneys and any pressing pains.

Diagnostic Basis:

TCM: The patient has lost hearing of his both ears for 13 years. He could understand lip readings. His spiritual activity was good. There was no restriction with his movement. There was ulcer in his mouth. His yellowish tongue was covering with some little red papules. He liked to drink cold water. His appetite was normal. Urine was yellowish and stool was soft. Pulse of his right hand was powerful and rapid, while left thready and rapid. Therefore, his condition could be diagnosed as deafness.

Western Medicine: The patient has lost hearing of his both ears for 13 years. He could understand lip readings. His spiritual activity was good. There was no restriction with his movement. There was ulcer in his mouth. His yellowish tongue was covering with some little red papules. He liked to drink cold water. His appetite was normal. Urine was yellowish and stool was soft. Therefore, his condition could be diagnosed as deafness.

Diagnostic Differentiation:

TCM: The patient¡¯s condition should be differentiated with diabetic deafness. For the diabetic deafness, the patient should have a history of years of diabetics and deafness was just an accompanied symptom. So, it was easy to differentiate them.  

Western Medicine: His condition should be differentiated from traumatic and senile deafness. For old people, deafness of them is due to insufficiency of kidney essence, and their hearing was decreasing little by little. While traumatic deafness was led by rupture of the eardrum, which is caused by trauma. So, it was easy to differentiate them.

First Diagnosis:

TCM: Deafness.  

Symptom identification: insufficiency of kidney essence and liver fire flam upward.

Western Medicine: Deafness.

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢̣ care.

3. Warm diet and water.

4. Pathogenesis: insufficiency of kidney essence and liver fire flam upward.

5. TCM strategy: fortify and benefit the kidney essence as well as clear the liver and drain fire.

6. Herbal tea: one dosage a day and drink twice

7. Acupuncture and massage: once a day

8. Have more medical examination if necessary.

Date: May 13, 2011                                         Time: 10:00 am

This morning, Professor Yang Qingzhi paid a visit to the patient. The patient has lost hearing of his both ears for 13 years. He could understand lip readings. His spiritual activity was good. There was no restriction with his movement. Appetite and sleep were good. He had no night urination. There was ulcer in his mouth. He suffered headache sometimes. His yellowish tongue was covering with some little red papules. He liked to drink cold water. His appetite was normal. Urine was yellowish and stool was soft. Pulse of his right hand was powerful and rapid, while left thready and rapid. The patient lost hearing without any external cause, and because the kidneys are open into the ears; therefore, his conditions was due to insufficiency of kidney essence, which could not give birth to marrow supplementing the ears. Symptom of irritability was due to fire stagnation of the liver meridian. Dryness in the mouth was due to yang brightness with over heat damaging body fluids. Symptoms of yellowish urine and red tongue with thin and yellowish tongue coating were due to heat inside the body. Therefore, the treatment should be fortifying and benefiting the kidney essence as well as clearing the liver and draining fire. 

Date: May 17, 2011                                         Time: 10:00 am

The patient said the amount of water intake was reduced a lot, but the total volume of water-intake was still much. His ulcer was better. After checking his hearing, the improvement was not too much. Pulse of his left hand was still weak. Color of his thorns and tongue coating was lighter.

Date: May 23, 2011                                         Time: 10:00 am

Water-intake of the patient was normal. Tongue coating became white now. Color of the thorns on the tongue coating became lighter. There was no evident improvement in his hearing.

Date: May 28, 2011                                         Time: 10:00 am

There were some cracks on his tongue body and coating, but did not drink too much water. His tongue coating was pale with thorns.

Date: May 31, 2011                                         Time: 10:00 am

The patient¡¯s tongue body and tongue coating were more moistening than before. The color of the thorns was lighter than before.

Date: Jun. 3, 2011                                         Time: 10:00 am

There were some changes in the patient¡¯s hearing. Continue the previous formula.

Date: Jun. 6, 2011                                          Time: 10:00 am

The patient felt some improvement in his hearing. The thorn points were still evident, but better than before. Continue the previous prescription.

Date: Jun. 15, 2011                                          Time: 10:00 am

The patient said his hearing was increased somewhat. Color of the thorns was lighter. His tongue coating became white. Continue the previous formula.

Date: Jun. 20, 2011                                          Time: 10:00 am

The patient had good spirit. Appetite and sleep were good. There was no bitterness in his mouth. The thorns were better. His tongue coating was thin and white. Hearing test: external auditory canal of both ears was clean. There was no tympanic membrane perforation.

Date: Jun. 25, 2011                                          Time: 10:00 am

The patient said he felt dry in his mouth. Urine was yellowish. He also had headache with a little bit coughing and slightly asthma. His pulse was floating and rapid. His tongue was slightly red and dry.

Date: Jun. 30, 2011                                          Time: 10:00 am

The patient got recovered from cold. The amount of urine increased. Water-intake was reduced. No more cough and asthma. His tongue was slightly red and dry.

Date: July 5, 2011                                          Time: 10:00 am

The patient opened the window, and he now could hear the noise made by the machines and cars on the road, which manifested that there were evident and great improvements in his hearing. His pulse was slightly thready and rapid.

Date: July 15, 2011                                          Time: 10:00 am

In the recent days, the patient was in good mood, but he felt slight dryness in his mouth. His tongue was red with evident reddish thorns. His pulse was rapid.

Date: July 20, 2011                                          Time: 10:00 am

Hearing of the patient was increasing. Dryness in the mouth was reduced. His tongue was slightly white with thorns.

Date: July 25, 2011                                          Time: 10:00 am

Dryness in the patient¡¯s mouth was further reduced. The thorns over the tongue almost became white.

Date: Aug. 1, 2011                                          Time: 10:00 am

The patient felt good improvement in his hearing. His pulse was stable. His tongue was red with white coating.

Date: Aug. 8, 2011                                          Time: 10:00 am

The patient¡¯s condition was stable and better.

Date: Aug. 10, 2011                                         Time: 10:00 am