Brief
Summary:
On
April 27, 2015, Mr. Zhou Jianping, from Zhongfang County near our hospital,
who had been suffering from headache and dizziness for more than 8 years, being
severe for 5 days. He was hospitalized in our hospital. His condition got great
improvement after 16 days TCM treatment with the help of Acupuncture, Herbal tea
and Tuina in our hospital.
Record of
Hospitalization
Name: Mr.
Zhou Sex: Male
Age: 40
Marital
Status: Married
Nationality: China
Date of Admission: April
27, 2015
Companion: Alone
First Medical Record
Date: March.
26, 2015 Time: 11:00
a.m.
This 62-year-old man had
been suffering from repeated joint-pains over his lower limbs for more than 4
years, being severe for half month. The patient was hospitalized in our hospital
for TCM treatment as a patient with gouty arthritis at
10:00 a.m. on March 26, 2015.
Essential for Diagnosis:
1. The patient had been
suffering from repeated joint-pains over his lower limbs for more than 4 years,
being severe for half month. He had no allergy history of any medicine or any
food.
2. When the patient came
to our hospital, he suffered the redness and swelling of knee-joits and foot
thumb joints, accompanied with burning pains, especially his knee-joints. He
could not stand and walk for a long time. The function of stretching and bending
his joints was limited, yet it was not related with the weather changes.
Sometimes he had dizziness and tinnitus, decreased hearing and soreness and
weakness of his waist. His appetite and sleeping were good. And the urination
and bowel movement were normal.
3. T: 36.5¡ãC R: 20
times/minute P: 88 times/minute BP: 150/90mmHg
4. The
patient grew normally. He was alert and cooperative. He had chronic sick facial
and flushing complexion. He was in compulsive position. There was no sign of
yellow sclera or yellowish skin. There was no enlargement on the superficial
lymph node of his whole body. His neck was soft without resistant, he could turn
his neck flexibly. His windpipe appearance was good and in the center. There was
slight distention of jugular vein. There was no enlargement on his thyroid
gland. His chest was symmetrical. Sound of breathing in the lungs was clear,
without any rhonchi. Rhythm of his heart was 88 times per minute. Heart rate was
regular with no murmurs. We did not hear any pathologic sound. His abdomen was
soft with no pressing pains, rebound tenderness and enclosed mass. There was no
sign of deformity over his spine. There was no obvious pressing pains around his
lumbar vertebra. The knee-joints of his lower limbs was obviously red and swell
with pressing pains. There was large swelling of his foot thumbs. The function
of stretching and bending over his knee-joints was limited. No pathological
neuropathic positive. His tongue was dark red with yellow coating. His pulse was
deep, rapid and unsmooth.
Diagnostic
Differentiation:
TCM:
Pains Impediment
Western
Medicine diagnosis:
Gouty arthritis
Treatment strategy and
nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade ¢ò care.
3. Diet of low salt and
low fat. Monitoring the blood pressure, once a day.
4. Completed the related
examination,
three
routine inspection, the function of the kidneys and the liver, blood fat, blood
sugar, anti-O, RF and IMX..
5. Herbal tea: one
dosage a day and drink twice
6. Acupuncture and
massage: once a day
7.
Avoid
wind-cold, regular daily life, have a good mood and take care of diet.
¡¡
Date: March 27,
2015 Time: 10:00 a.m.
Dr. Ming,
doctor-in-charge, paid a visit to the patient this morning. The patient suffered
repeated joint-pains over his lower limbs for more than 4 years, being severe
for half month. Recently, she suffered the redness and swelling of knee-joits
and foot thumb joints, accompanied with burning pains, especially his
knee-joints. He could not stand and walk for a long time. The function of
stretching and bending his joints was limited, yet it was not related with the
weather changes. Sometimes he had dizziness and tinnitus, decreased hearing and
soreness and weakness of his waist. His appetite and sleeping were good. And the
urination and bowel movement were normal. He was in compulsive position. The
knee-joints of his lower limbs was obviously red and swell with pressing pains.
There was large swelling of his foot thumbs. The function of stretching and
bending over his knee-joints was limited. According to the above condition, Dr.
Made the treatment strategy.
¡¡
Date: March 30,
2015 Time: 9:00 a.m.
The patient said he felt
the pains of his knee-joints relieved. He could walk for about 100 meters. His
appetite and sleeping were better. The dizziness was better, while the tinnitus
was the same. And he still feel weakness and soreness of his waist. His
urination and bowel movement were normal. There was obvious pressing pains over
his foot thumbs and knee-joints.
¡¡
Date: April 1,
2015 Time: 9:00 a.m.
Test
reports:
Urine
routine shows normal. The report of the blood routine, oxyphil cells 0.52¡ü;
neuter cell rate 70.40¡ü;
lymphocyte rate 16.1%; oxyphil cells rate 5.40¡ü;
hemoglobin 173¡üG/L;
HCT 0.265¡ü;
MCV 102.50¡ü,
etc. According to the reports, doctor adjusted his formula.
Date: April 5,
2013 Time: 9:00 a.m.
The vital signs of the
patient were stable. And his spirit status was obviously better. And the redness
and swelling of his knee-joints and foot thumbs relieved greatly, he could walk
for 1 to 2kilimeters. And his appetite was better. The sleeping was normal. Yet
he still feel weakness and soreness over his waist. The color of urine was
yellow. The pressing pains improved obviously over his knee-joints. And the
function of stretching and bending was already normal. The tongue body was dark
red with thin and yellow coating. The pulse was string and slippery.
¡¡
Date: April 9,
2013 Time: 9:00 a.m.
The patient said the
joint-pains of his four limbs almost disappeared. He could walk flexibly and
normally. His appetite and sleeping were normal, as same as his urination and
bowel movement.
¡¡
Date:
April 13, 2013 Time: 9:00 a.m.
The vital signs of the patient were stable. The patient said
the joint- pains disappeared completely. He could move his joints normally. The
tinnitus was also improved. And his vision was better than before. There was no
obvious pressing pains over his knee-joints. The tongue coating was thin and
yellow. The pulse was string and slow. The patient decided to leave the hospital
today.
¡¡
