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Brief Summary: On Apr. 15, 2009, Melkam from Ethiopia, who has suffered from headache and blurred vision for one year, was hospitalized in our hospital. The patient said she had achieved 75% improvement after 23 days TCM treatment here.

 

Record of Hospitalization

Name: Melkam                                                                                                    Birthplace: Ethiopia

Sex: Female                                                                                                         Profession: Businessman

Age: 31                                                                                                                Date of Admission: Apr. 15, 2009

Nationality: Ethiopia                                                                                            Date of Record: Apr. 15, 2009

Marital Status: Married                                                                                      Onset Season: Vernal equinox

Complainer: The patient herself

 

First Medical Record

Date: Apr. 15, 2009                                      Time: 23: 00 p. m.

Melkam, a 31-year-old female, has suffered from headache and blurred vision for one year. She was hospitalized in our hospital for treatment at 23: 00 p. m. on Apr. 15, 2009.

Essentials for Diagnosis:

1. The patient has suffered from headache and blurred vision for one year.

2. Last April, the patient felt headache without obvious reasons. The headache became more serious when she touched the head. Meanwhile, she had the symptom of blurred vision. At that moment, she didn¡¯t pay much attention to it and hadn¡¯t taken any examination and treatment. Later her condition gradually became worse. So last October she went to a local hospital for examination and was diagnosed with intracranial hypertension. Then she was given the extracting of cerebrospinal fluid to relieve intracranial pressure. Her headache lessened and the blurred vision disappeared after the reduction of the pressure. Besides, she didn¡¯t take any other treatment. So she went to our hospital for further treatment at 23: 00 p. m. on Apr. 15, 2009. She had pale red tongue, thin white tongue coating, thready and weak pulse.

3. T 36.3¡æ, P 80 times/minute, R 20 times/minute, BP 110/70mmHg.

4. She grew normally with common nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. Her body was in a positive posture and she was cooperative with clear mind.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The patient had the symptoms of headache, blurred vision and tinnitus.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient has suffered from headache and blurred vision for one year. Her condition broke out repeatedly. Due to the obstruction of the channels and network vessels, the essence as well as the blood could not reach the brain, then the patient felt headache.

Western Medicine: The patient has suffered from headache and blurred vision for one year, accompanied with the symptom of tinnitus.

Diagnostic Differentiation:

TCM: The patient¡¯s headache should be differentiated from unendurable headache, which is accompanied with the symptoms of sudden onset, intense, continuous and paroxysmal headache and vomiting like spurting. The patient will die if the patient hasn¡¯t taken the proper treatment in time. So they are not difficult to be distinguished.

Western Medicine: The patient¡¯s headache should be differentiated from nerve headache. Regarding nerve headache, the onset of the part is not fixed, usually accompanied with the symptoms of tightening sense, heavy sense, numb pains, distending pains and stabbing pains, which are closely connected with mood swings, tiredness, insomnia, etc. So they are not difficult to be distinguished.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Headache

Symptom identification: Qi stagnation and blood stasis.

Western Medicine diagnosis: Headache

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Under the care of a companion.

4. Common diet.

5. TCM treatment strategy: move qi, quicken the blood circulation, relieve pains, settle heaviness and clear downbearing.

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: Apr. 16, 2009                                      Time: 12: 00 a. m.

The patient has suffered from headache for one year. The headache became more serious when she touched the head. She was given twice extracting of cerebrospinal fluid to relieve intracranial pressure in last October and December. Her double vision and blurred vision disappeared after the reduction of the pressure. But she still felt distending pains of the head, tinnitus, the stiffness and pains of the neck and the muscles of the upper limbs. The head was mainly characterized by distending pains, accompanied with the symptom of needling pains of the back of the eyes. In 2002, she suffered from HSV-II. The onset time of HSV-II was nearly the same as that of the symptoms of the discomfort of the neck and the stiffness of the muscles. The result of recheck showed that the virus was negative after she had taken antiviral medicine for one year. Her diet and spirit were generally good. There was no symptom of vomit. She took 2 pills of Panadol every night to relieve pains. The function of the heart and lungs were normal. Her abdomen was soft. There were no pressing pains in the area of the liver. She had pale red tongue, thin white tongue coating, thready and weak pulse. So the treatment strategy was to move qi, quicken the blood circulation, relieve pains, settle heaviness and clear downbearing. The prescription was as follows: chenpi (tangerine peel), chuanxiong (ligusticum root), chuanlianzi (toosendan fruit), etc. 3 dosages in total.

 

Date: Apr. 18, 2009                                      Time: 18: 00 p. m.

The patient said the distending pains of the head were improved 25%. Moreover, she stopped to take Panadol in the recent three days. Her sleep was still not good. Her diet was good. The former prescription was changed a little. 3 dosages in total.

 

Date: Apr. 21, 2009                                       Time: 9: 00 a. m.

The patient has suffered from headache for one year with paroxysmal aggravation, especially the forehead and afterbrain. She was diagnosed with intracranial hypertension in the local hospital, accompanied with the symptoms of tinnitus and dizzy vision. Her spirit was not good. Her stomach duct was bloating. She could feel the pains of sternal rib before the menstruation. The color of menstrual blood was dark. Besides, she felt the pains of the waist. She had pale red tongue, thin white tongue coating, thready and weak pulse. So the treatment strategy was to course the liver, rectify qi, quicken the blood circulation and free the vessels. The prescription was as follows: baishao (white peony root), chaihu (bupleurum root), chuanxiong (ligusticum root), etc. 4 dosages in total.

 

Date: Apr. 25, 2009                                       Time: 9: 00 a. m.

The patient said the headache and dizzy vision lessened. There were pains of the muscles, sinews and bones. The first day of her last menstruation was Apr. 3. Besides, she had distending pains of sternal rib before menstruation. The color of menstrual blood was dark with stasic blood macules. Her menstrual flow was scant. She seemed to be well-built. The former prescription was changed as follows: baizhi (angelica root), huangqi (astragalus root), honghua (carthamus flower), etc. 5 doages in total.

 

Date: Apr. 30, 2009                                       Time: 9: 00 a. m.

She had menstruation on Apr. 28. The headache obviously lessened. But there were distending pains of the neck and waist. The prescription was changed as follows: gancao (licorice root), gouqi (lycium berry), gegen (pueraria root), etc. 4 dosages in total.

 

Date: May 4, 2009                                        Time: 9: 00 a. m.

There were the symptoms of paroxysmal distending pains of the neck, shoulders, arms and head as well as dizziness. Sometimes, she could feel the pains of the waist and legs. She had even been diagnosed with cervical spondylosis and lumbar spondylosis in the local hospital. Today she required the doctor focus on the treatment of the above diseases. The prescription was changed as follows: gegen (pueraria root), taoren (peach kernel), jiaogulan (gunostemma), etc. 4 dosages in total.

 

Date: May 7, 2009                                        Time: 9: 00 a. m.

The headache obviously improved, but there were paroxysmal pains of the neck, shoulders, back, waist and legs. Today she decided to leave the hospital with taking 30 days herbal tea for continuous treatment of cervical spondylosis and lumbar spondylosis.

 

Room 304

06 05 2009

 

I patient Melkam Temesgen from Ethiopia came to Huai Hua Red Cross Hospital 23 days ago. I came here with a complain of cervicald cumbar spondilosis and idopathic intracrinial hypertention, and after spending one week of TCM treatment, my health condition start improve which is the happiest moment of my life.

 

I thank all the translators without them, i couldn't image the treatment, they are the back bone of this hospital.

 

My sincere appreciation to Dr.Ming, Dr.Lini, Professor, Zhang xiukui, Dr.Liu youhui, for the care and attentiveness.

 

I also would like to thank the rest of the hospital team for their support and assistance.

 

We expect the new TCM hospital to have more improved standards for the international paients department.

 

Thank you very much all!

 

God bless China and the rest of the world!

 

Melkam Temesgen

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