TCM China:

Record of Herbal Treatment Of Yuzhu Guo from Indonesia Improvement Of Dizziness and Tinnitus

 

 

 

 

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Brief Summary: On June. 08, 2014, Yuzhu Guo, came from Indonesia, who suffered from dizziness and tinnitus for 5 years. She was hospitalized in our hospital. She got some improvement after 16 days TCM treatment.

 

Record of Hospitalization

Name: Yuzhu Guo                                                          Sex: Female

Age: 69                                                                          Marital Status: Married

Nationality: Indonesia                                                    Date of Admission: Jun. 08, 2014

Companion: Nobody

 

First Medical Record

Date: June 08, 2014                         Time: 10:00 a.m.

Yuzhu Guo, female, 69 years old, had suffered from dizziness and tinnitus for 5 years. The patient was hospitalized in our hospital for TCM treatment at 10:00 a.m. on June 08, 2014.

 

Essential for Diagnosis:

1. The patient had suffered from dizziness and tinnitus for 5 years. And it was rotatory vertigo, but with no vomit, no palpitations and no insomnia. There were no medicine and food for her to get allergy response.

2. The patient was 69 years old now. Before she had a good health. She had a child with normal childbirth. She had hypotension. 5 years ago the vertigo and tinnitus began to attack her. But recently she had dizziness, tinnitus, pains over her cervical spine and thoracic vertebra, palpitations and insomnia. She felt sore all over her body. There was no dry mouth. And her appetite was normal. The color of urine was white. And her bowel movement was normal, but a little soft.

3. T: 36.3°C   R: 20 times/minute    P: 80 times/minute   BP: 112/56mmHg

The patient had normal growth, physique and spiritual activity, while with chronic disease face. There was no hyperaemia and edema in her throat. Her neck was soft without resistance stiffn. Sound of breathing in her lungs was clear. Her chest was symmetrical. Rhythm of her heart was a little slow. Heart rate was irregular. Her abdomen was soft without pressing pains and rebound tenderness. The result of Murphy’s sign was negative. The meningeal irritation syndrome was also negative, without the other pathological reflex. The tongue was thin with white coating. The pulse was deep, wiry and irregular.

4. Examination: The result of X-ray showed that her thoracic vertebra and intervertebral disc degenerated. 

 

Diagnostic Basis:

TCM: Dizziness and tinnitus

Western Medicine: Dizziness and tinnitus

 

 Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade care and common diet.

3. To apply for the three routine inspection, the function of kidneys and liver.

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

5. Acupuncture and massage: once a day

6. Relax mind, regulate emotion and living timetable.

 

Date: Jun. 08, 2014                                    Time: 11:00 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient was 69 years old now. Before she had a good health. She had a child with normal childbirth. She had hypotension. 5 years ago the vertigo and tinnitus began to attack her. But recently she had dizziness, tinnitus, pains over her cervical spine and thoracic vertebra, palpitations and insomnia. She felt sore all over her body. There was no dry mouth. And her appetite was normal. The color of urine was white. And her bowel movement was normal, but a little soft. According to TCM diagnosis, Dr. Ming made the treatment plans. 

 

Date: Jun. 09, 2014                                    Time: 10:00 a.m.

The patient said there is no obvious change. She still had dizziness and tinnitus. And she refused to do the blood test.

 

Date: Jun. 10, 2014                                    Time: 10:00 a.m

The Blood pressure went up to 118/60 mmHg. The vertigo and tinnitus were relieved.  And her palpitations were improved.

 

Date: Jun. 12, 2014                                    Time: 10:00 a.m. 

The patient said recently days she had no dizziness and tinnitus. Her pulse was much smoother than before. But her sleep was not good.

 

Date: Jun. 17, 2014                                    Time: 10:00 a.m.

The patient said her dizziness and tinnitus disappeared. And her sleep was better. The pulse was smooth.

 

Date: Jun. 23, 2014                                    Time: 18:00 p.m.

The patient decided to leave our hospital.