Benqian Sex: Male
Marital Status: Married
Date of Admission: Jan. 26, 2015
First Medical Record
Date: Jan. 26,
2015 Time: 10:00 a.m.
This 65-year-old man had
been suffering from recurrent pains over his knees for more that 10 years and expectoration for half a year. He was hospitalized in our
hospital as a patient with hyperostosis over his knees for TCM treatment at
10:00 a.m. on Jan. 26, 2015.
Essential for Diagnosis:
1. In the past, the
patient always had pains over his knees. In April, 2015, he was hospitalized in
the hospital because of cerebral hemorrhage. Yet his condition improved after
hospitalization. There were no food and medicine for him to get allergy
2. When the patient came
to our hospital, there were pains over the joints of his knees, especially his
right knee-joint. He could not climb up and down the stairs. The pains were
bearable when he walked. And the pains were related with the changes of the
weather. Whatever the weather was getting cold or hot, the pains got worse. In
recent days, when he walked, it was difficult to bear the pains. There was no
other discomfort. His urination and bowel movement were normal.
3. T: 36.5＜C R: 20
times/minute P: 78 times/minute BP: 150/120mmHg
4. The patient had
normal growth, physique and spiritual status. He cooperated with doctors when
the physical examinations were made. He was in compulsive position. There was no
yellow skin or yellow sclera over his whole body. There was no enlargement over
his superficial lymph node. His neck was soft with no resistance. He had regular
features. The pupils were round and approximately equal in size. The pupillary
reaction to the light was sensitive. His trachea was symmetrical. There was no
enlargement over his thyroid. The jugular vein was of no engorgement. His chest
was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi.
Rhythm of his heart was 78 times per minute. Heart rate was regular with no
murmurs. His abdomen was soft with no pressing pains and rebound tenderness.
There were no signs of Murphy. There was no sign of deformity over his spine.
There were no obvious pressing pains. There was no edema over his lower limbs.
And there were obvious pressing pains around his right knee-joint, with slight
swelling. There was movement limitation over his right knee-joint. The nerve
pathological reaction was negative. The tongue body was dark red with yellow
coating. The pulse was taut and slightly unsmooth.
5. Imaging examination
at the No. 3 People¨s Hospital in Huaihua, the result showed that he had
hyperostosis over his right knee-joint.
Hyperostosis over his right knee-joint
2. Sequel of cerebral
infarction and hypertension
Treatment strategy and
1. Routine care of
traditional Chinese internal medicine.
2. Grade Å care,
companion, common diet.
3. Complete the related
examination, three routine inspection, the function of the kidneys and the
liver, blood fat, blood sugar and IMX.
4. Herbal tea: one
dosage a day and drink twice
5. Acupuncture and
massage: once a day
6. Avoid wind-cold,
regular daily life, have a good mood and take care of diet.
Date: Jan. 27, 2015
Time: 10:00 a.m.
doctor-in-charge, paid a visit to the patient this morning. This 65-year-old
man had been suffering from recurrent pains over his knees for more than 10
years. His condition was unstable. In recent years, his condition was getting
worse. He could not climb up and down the stairs. He could not stand for a long
time. There was the movement limitation over his right knee-joint. And the pains
were related with the changes of the weather. Whatever the weather was getting
cold or hot, the pains got worse, especially his right knee-joint. In recent
days, when he walked, it was difficult to bear the pains. And there were obvious
pressing painsa round his right knee-joint. The doctor combine with his history
of sequel of cerebral infarction to make a proper treatment strategy.
Date: Jan. 29, 2015
Time: 9:00 a.m.
The patient said the
pains over his knee-joints relieved. His sleeping was good. But when he climbed
up and down stairs, he still could not bear the pressure. He felt powerless over
his knees. Checked up his body: There were pressing pains over his knee-joints,
especially his right knee-joint, the pains were obvious. His tongue coating was
yellow. His pulse was taut and unsmooth.
Date: Feb. 01, 2015
Time: 9:00 a.m.
The patient said the
pains over his knee-joints obviously relieved. And the movement of his
knee-joints was better than before, yet he still could not walk too fast. His
appetite was good, and his urination and bowel movement were normal. The doctor
checked his knee-joints, the pressing pains greatly improved.
Date: Feb. 04, 2015
Time: 9:00 a.m.
The vital signs of the
patient were stable. The patient said the pressing pains over his knee-joints
obviously improved. He could climb up and down the stairs. And he could move his
knees flexibly. The patient decided to leave the hospital today.
Doctor¨s advice after
1. Avoid wind-cold.
2. Take care of the
3. Take the herbal
medicine back for consolidating the treatment.