Name: Hauwa                                                                                                      Sex: Female

Age: 64                                                                                                                Marital Status: Married

Nationality: Nigerian                                                                                            Date of Admission: May 22, 2011

Companion: Alone

First Medical Record

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

This 64-year-old lady had been suffering from hypertension for eight years, accompanied by fatigue, dizziness, headache and blurred vision. The patient was hospitalized in our hospital for TCM treatment at 7 am on May 22, 2011.

Essential for Diagnosis:

1. The patient had been suffering hypertension for eight years, accompanied by fatigue, dizziness, headache and blurred vision.

2. Eight years ago, she was checked out hypertension and the highest number was 190/120 mmHg. Her condition turned better after using the medicines of Uisinopril, Aldactone, Carredidal. When the patient came to our hospital, she felt weakness, shortness of breath, blurred vision, dizziness, and headache. She felt dryness in her mouth and liked cold drinks. She also suffered reoccurrence of mouth ulcer. She had no fetid breath and no bitterness in her mouth. There sometimes was phlegm in her throat; when the phlegm was much, she needed phlegm spray to help her breathe. She suffered pains over her upper limbs. Edema was shown over the parts down her knees. Her hands and feet were cold. Her appetite was bad. Bowel movement was normal. Her urine was yellowish. She had night urination once per night. 35 years ago she did an operation for the metrofibroma. Her tongue was dry with cracks. Both sides of her tongue were dark. Her tongue was red with yellowish tongue coating. Her pulse was sunken, thready and weak.

3. She was healthy before, but allergic to shrimps and aspirin.

4. T: 36.5＜C   R: 20 times/minute    P: 82 times/minute   BP: 140/80mmHg

5. The patient grew normally. Her spiritual activity was not good. She had chronic disease complexion. She walked very slowly.

Diagnostic Basis and Differentiation:

TCM: The patient had suffered from suffered from hypertension for eight year, accompanied by fatigue, shortness of breath, blurred vision, dizziness and headache. There was phlegm in her throat. Her hands and feet were not warm. Her tongue was dry with cracks. Her tongue was red with yellowish tongue coating. Her pulse was deep, thready and weak. These symptoms belong to dizziness, which is due to hyperactivity of liver-yang and blood stasis obstructing channels. Dizziness should be differentiated with headache. Blurred vision is the main symptom of dizziness, which is internal injury; while pains over the head are the main symptom of headache, which relates to internal injury and exogenous affection.

Western Medicine: Blood pressure of the patient had been rising for eight years. She felt tired, shortness of breath, blurred vision, dizziness and headache. She also suffered edema over the parts down her knees. Her conditions were diagnostic as hypertension. Her condition should be differentiated with renal parenchymal hypertension. For patient with renal parenchymal hypertension, they usually have the history of nephritides or urinary system infection.

First Diagnosis:

TCM: Dizziness.

Symptom identification: hyperactivity of liver-yang and blood stasis obstructing channels. 

Western medicine: Hypertension, ventricular failure

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade I care.

3. Diet of low salt and low fat. Foods are easy to be digested.

4. Pathogenesis: hyperactivity of liver-yang and blood stasis obstructing channels

5. TCM strategy:to calm the liver and subdue yang, to remove blood stasis and free the channels.

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

7. Acupuncture and massage: once a day

9. Have more medical examination if necessary.

Date: May 24, 2011                                            Time: 10:00 am

This morning, Dr. Zhu Ming paid a visit to the patient. The patient complained that she was very tired and weak. She also suffered shortness of breath, blurred vision, dizziness and headache. She felt dry in her mouth with reoccurrence of mouth ulcer. Both upper limbs were painful. Edema showed over the parts down her knees. Her hands and feet were not warm. Appetite was not good.

Bowel movement was normal. Urine was yellowish with night urination once a night. Blood pressure was 170/90 mmHg. Her tongue was red and dry with cracks. There was yellowish tongue coating in the middle of her tongue body. Her pulse was deep, thready and week. According to the theory of TCM, her condition could be diagnosed as dizziness, which was due to hyperactivity of liver-yang and blood stasis obstructing channels. The treatment for her condition was to calm the liver and subdue yang, and to remove blood stasis and free the channels.

Date: May 26, 2011                                            Time: 10:00 am

The patient said there was no dizziness and headache any more, but blurred vision still existed. When she opened her eyes, she saw many black lines flying backwards. Symptoms of shortness of breath, weakness and dryness in the mouth stilled existed. The patient said she felt pains over the joints of her whole body and pains over her back and legs. She said she suffered such reoccurrence of pains for more than ten years, which was not related to the change of weather. Lower limbs were still swelling. Bowel movement and urination were normal. Blood pressure today was 138/75 mmHg. Her tongue was red with cracks. Both sides of her tongue were dark. Her pulse was deep, thready and weak.

Date: May 27, 2011                                            Time: 10:00 am

The patient said pains were reduced. Other condition was like the above mentioned. The day before came to our hospital, she stopped all the medicine for her hypertension. The doctor advised her to have enough rest.

Date: May 30, 2011                                            Time: 10:00 am

The patient said there were no more back pains. Pains over her upper limbs were reduced, but pains still existed over her outside part of her lower limbs. Mouth ulcer was much better. She still felt dryness in her mouth and shortness of breath. Dorsal parts of her right fingers were painful, and when being touched, she felt like being burned by hot water. Her fingers were stiff, and when making a fist, she felt numbness over her fingers. Such symptoms had been for 6 years. According to her condition, some changes had been made in her prescription.

Date: June 2, 2011                                             Time: 10:00 am

The patient said pains over her right fingers were reduced. Joints of her little fingers were painful, while pains over her general whole body were reduced evidently. She still felt shortness of breath; even she just walked ten steps. Both lower limbs were still swelling.

Date: June 7, 2011                                             Time: 10:00 am

The patient said she felt more relaxed when walked. Pains over her whole body turned better. No more dizziness and headache. Swelling over her lower limbs was reduced. While when walked for a long time, she still felt shortness of breath and chest depression.

Date: June 12, 2011                                             Time: 10:00 am

 The patient said pains over her whole general body were reduced obviously. She suffered no more headache and mouth ulcer. Shortness of breath was better and no more chest depression.

Date: June 14, 2011                                             Time: 10:00 am

Due to the change of weather, the patient felt uncomfortable on her throat with viscous sputum in her throat.

Date: Jun. 19, 2011                                              Time: 10:00 am

Hauwa said there was no discomfort in her throat. She suffered no more headache and dizziness. Pains over her whole general body were alleviated a lot. No more mouth ulcer. She suffered no shortness of breath and chest depression even walked for a little bit long distance. Swelling over her lower limbs was reduced. Blood pressure was 140/80 mmHg. For the expiration of visa, she decided to leave our hospital today.

Doctor¨s advice after leaving hospital:

1. Avoid wind-cold, maintain good moods.

2. Take herbal tea back for continuing treatment.