Brief
Summary:
Ms. Maryam had been suffering from too much drinking, too much
urination as well as repeated headache for 18 years, accompanied
by edema over her lower limbs for 6 months. She was diagnosed as
chronic renal insufficiency. She was hospitalized in our
hospital on September 27, 2013 for TCM treatment. She achieved
significant improvement after nearly 2 month TCM treatment with
the help of herbal tea, acupuncture, massage etc.
Condition before TCM treatment:
Patient with polydipsia, polyuria, and recurrent headaches for
18 years, lower limbs swelling for six months, and then admitted
into our hospital with the head pain, feel dizziness when change
positions, blurred vision. Symptoms of dry mouth, polydipsia,
and polyuria have reduced after medication. Pain and tired in
right lower limbs after walking about 10 minutes. Swelling in
both lower limbs, and numbness in left toe. Check: P72 beats /
min, Bp170/90mmHg. Dark tongue, thick yellow dry coating with
crack, obviously sublingual stasis network, and deep thin
slippery pulse. Taking "Carvedilol" and other 9 kinds of drugs,
insulin 20 u / day. Admission examination BUN 23.1/mmol/l
↑,
UA 563umol / L
↑
serum creatinine 34umol / L .
Condition at Discharge:
Patient discharged without dry mouth, polydipsia, and polyuria.
No headache and dizziness. Easy walking than before, can
self-shopping now, reduced swelling in lower limbs, and no
numbness in feet. Check: P78 beats / min, Bp150/85mmHg. Shiny
complexion than before. Red tongue with thin yellow coating,
visible touching pulse. Taking "Carvedilol" and other four kinds
of drugs, insulin 14 u / day. Check blood urea nitrogen (BUN)
3.82 mmol/l, uric acid 408 umol/L, CR 194 umol/L.
Record of Hospitalization
Name:
Maryam Sex: Female
Age:
61 Marital Status: Married
Nationality:
Bahrain Date of Admission: Sep. 28, 2013
Companion:
Her Son
First Medical Record
Date:
Sep. 28, 2013 Time:
11:00 am
This 61-year-old lady had been suffering from too much drinking,
too much urination as well as repeated headache for 18 years,
accompanied by edema over her lower limbs for 6 months. The
patient was hospitalized in our hospital for TCM treatment at
22:00 on September. 27, 2013.
Essential for Diagnosis:
1. The patient had been suffering too much drinking, too much
urination as well as repeated headache for 18 years, accompanied
by edema over her lower limbs for 6 months.
2. The patient suffered the symptoms of much drinking, much
urination and repeated headache for 18 years. Six months ago,
she suffered edema of her lower limbs. After her last child was
born 18 years ago, because of high blood sugar, the upper limb
of her left hand was infected and festered; the part down from
her elbow was amputated. She also suffered hypertension, and she
still took many western medicine to control it. The symptom of
edema over her lower limbs appeared six months ago. She went to
her local hospital to take examination, and the result showed
chronic renal insufficiency.
3. When the patient was hospitalized in our hospital, she
suffered headache, swelling pains, without nausea or vomiting.
When she moves her body, she felt dizzy. She also suffered
blurred vision, with tears always rolling in her left eye. There
was no itchy symptom over her eyes, and also no symptoms of
tinnitus and deafness. Because using western medicine for her
conditions, she now felt dryness in her mouth, but the symptoms
of much drinking and much urination were alleviated. She did not
feel bitterness or bad breath odor in her mouth. She liked cold
drinking. She suffered shortness of breath with no palpitations.
There was no pains over her back. When she walked too long, she
felt pains over her right lower limb. Her lower limbs were
swelling, with numbness over her right toes. She was not afraid
of coldness. Her bowel movement was once a day. She had night
urination for 3 times. After controlling of her diet, her weight
decreased about 3-4 kg. Her blood pressure was controlled at
around 160/90 mmHg; blood sugar 16-17 mmol/L.
4. T: 36.3°C R: 20 times/minute P: 72 times/minute BP:
170/90 mmHg
5. Her spirit activity was good. She was a little bit plump. She
grew normally. The patient could move normally. There was no
enlargement of her superficial lymph node over her whole body.
Her face was dark with no burnish. The color of her eyelids and
lips was pale. Rhythm of her heart was 72 times per minute.
Heart rate was regular with no murmurs.
Sound of breathing in the lungs was clear, without any rhonchi.
We did not hear any pathologic sound. Her abdomen was soft with
no pressing pains, rebound tenderness and enclosed mass.
The part down from her elbow was amputated. There were slight
edema over her lower limbs. Her tongue was dim with yellowish,
thick and dry tongue coating. There were tooth marks over her
tongue surface. There obvious stasis texture below her tongue.
Her pulse was deep, thready, wiry and smooth.
6. Other tests at her local hospital on August
19, 2013:
Blood-FPG 7.9 mmol/L, HBAIC 90mmol/mmol, Cr 416
umol/L, urea 27.1 mmol/L, UA 586umol/L, Cho 6.6 mmol/L, LDL-cho
4.07 mmol/L, TG 2.9 mmol/L, SB 19 mmol/L, P 2.3 mmol/L.
September 7, 2013: RBC 3.57*1012/L, Hb 9.6 g/dl, BUN
33.1 mmol/L, Cr 457 umol/L, Na 129 mmol/L, K 5.5 mmol/L, P 2.08
mmol/L.
Diagnostic Basis:
TCM:
According to the symptoms of much drinking, much urination and
repeated headache for 18 years, edema over her lower limbs for
six months, occasional milky white urine with foam, dizziness
when changing body position, her condition should be
thirst-depletion, dizziness and kindey turbidity in the category
of TCM. Long course of disease caused the deficiency of
kidney-yin, which led to the symptoms of thirst-depletion and
dizziness. The deficiency of liver-yin caused hyperactivity of
yang, and then blood pressure went high. Fire excess from Yin
deficiency disturbed upwards to the head and eyes, which led to
blurred vision, tearing, headache and preferring cold drinking.
Deficiency of kidney could not help the spleen to transport the
dampness inside the body, which led to edema of the lower limbs.
Her condition should be thirst-depletion, dizziness and kidney
turbidity in TCM due to yin deficiency of kidney and liver as
well as qi insufficiency of lungs and spleen.
Western Medicine:
1. Much drinking, much urination and repeated headache for 18
years. Edema over her lower limbs for 6 months.
2. Blurred vision, always tearing of her left eye. Milky white
urine with foam sometimes. Shortness of breath. Numbness over
the toes of her left foot. Night urination for 3 times.
3. Her face was dark with no burnish. The color of her eyelids
and lips was pale.
4. Examination in her local hospital: 11.4%AIC, BUN 33.1 umol/L,
CR 457 umol/L, UA 586 umol/L.
First Diagnosis:
TCM:
Kidney turbidity, dizziness and diabetes.
Symptom identification: yin deficiency of liver
and kidneys as well as qi insufficiency of the lungs and spleen.
Western Medicine:
Chronic renal insufficiency,
Diabetic Nephropathy,
Type
Ⅱ
diabetics,
Hypertension Degree
Ⅱ
Treatment strategy and nursing:
1. Routine care of traditional Chinese internal medicine.
2. Grade I care.
3. Companion.
4. Diet of low salt, low fat, low sugar and low protein.
5. Pathogenesis: yin deficiency of liver and
kidneys as well as qi insufficiency of the lungs and spleen.
6. TCM strategy:
tonifying Yin and clearing away heat, nourishing qi and
tonifying liver and kidneys.
7. Herbal tea: one dosage a day and drink twice
8. Acupuncture and massage: once a day
9. Have more medical examination if necessary.
Date: Sep. 29, 2013 Time:
09:00 am
This morning, Doctor Ming paid a visit to the
patient. The patient complained that she still felt headache,
blurred vision, tearing often in her left eye. Sleep was good.
She liked cold drink. She still felt shortness of breath, but
without palpitations. Lower limbs were of edema. Check: T:
36.4°C, R: 20 times/minute, P: 75 times/minute, BP: 200/94 mmHg.
Her face was dark with no burnish. The color of her eyelids and
lips was pale. Her tongue was dark with yellowish, thick and dry
coating. There were tooth marks over her tongue edges. There was
obvious stasis texture below her tongue. Her pulse was deep,
thready, wiry and smooth. According to her symptoms and the
examination from her local hospital, Dr. Ming thought her
condition should be thirst-depletion, dizziness and kidney
turbidity in TCM due to yin deficiency of kidneys and liver as
well as qi insufficiency of lungs and spleen. Therefore, the
treatment should be tonifying Yin and clearing away heat,
nourishing qi and tonifying liver and kidneys and freeing the
circulation of blood.
Date: Sep. 30,
2013 Time: 09:00 am
The patient said, because of time difference, she did not sleep
well last night. And this morning, she felt headache and tired.
Check: 170/90 mmHg. Blood sugar, yesterday, on an empty stomach:
11.0 mmol/L, before lunch: 16.0 mmol/L, 2 hours after lunch:
13.1 mmol/L, before dinner: 13.6 mmol/L, after dinner: 18.6
mmol/L. The patient said, her blood sugar was controlled between
16 mmol/L and 17 mmol/L, but it was still too high.
Date: Oct. 3,
2013 Time: 09:30 am
The patient said headache and cough had gone. She felt ok. Stool
was once a day. Edema over her lower limbs almost disappeared.
Her tongue coating was still yellow and white and slightly dry.
Her pulse was deep, thready, but not smooth.
Date: Oct. 5,
2013 Time: 09:30 am
The patient said there were no more headache and
dizziness, but still slight cough. Blood sugar, at 15:30
yesterday, 20.5 mmol/L, 18:30 11.2 mmol/L, Bp 158/78 mmHg. This
morning, on an empty stomach: 11.5 mmol/L.
Date: Oct. 9,
2013 Time: 09:00 am
This morning, Dr. Ming, doctor-in-charge, paid a visit to the
patient. She complained that sleep was good, without any cough.
Bowel movement was still not good. She felt distension over her
abdomen. She had night urination for 3 times. Yesterday, 8:00
a.m: 8.8 mmol/L, 11:00 a.m.: 12.8 mmol/L, 12:30 a.m.: 10.7
mmol/L, 6:30 p.m.: 3.4 mmol/L, 9:00 p.m.: 12.8 mmol/L. This
morning, 7.6 mmol/L.
Date: Oct. 16, 2013
Time: 09:00 am
The patient said bowel movement was normal now,
with twice a day. She did not felt abdominal distension and
cough. Sleep was good. This morning, blood sugar, on an empty
stomach: 10.7 mmol/L. Bp 150/80 mmHg.
Date: Oct. 19, 2013
Time: 09:00 am
The patient said that abdominal distension was better. Sleep was
normal. Appetite was good. Her pulse was wiry. Her tongue
coating was thick and white.
Date: Oct. 25, 2013
Time: 09:00 am
Yesterday, blood sugar, on an empty stomach: 14.0 mmol/L.
She did not take insulin injection on October 23. Because she
did not take enough breakfast at that day, and the blood sugar
was lower than 10 mmol/L, she was afraid to take insulin to
cause low blood sugar.
Date: Oct. 28, 2013
Time: 09:00 am
Yesterday morning, blood sugar, on an empty
stomach: 8.8 mmol/L. At 3 p.m.: 18.2 mmol/L. At 9 p.m. 17.6
mmol/L. In the morning of today, on an empty stomach: 6.6
mmol/L. Bp 160/90 mmHg. Her tongue was red, with yellow tongue
coating. Her pulse was wiry and smooth.
Date: Nov. 1, 2013
Time: 09:00 pm
Report of the examination of the liver and kidney functions:
Blood: TC 10.33 mmol/L↑,
TG 5.27 mmol/L, LDL 17.02 mmol/L↑,
TB 2.6 umol/L↑, DB 0.8 umol/L, BUN
15.97, UA 470 umol/L↑, Cr 186 umol/L↑, GLU 7.4 mmol/L. Blood-R:
HGB 95G/L, RBC 3.45*1012/L.
Yesterday morning, blood sugar, on an empty stomach: 8.1 mmol/L
↑.
The patient had good spirit. Bp 160/85 mmHg. She did not feel
dizziness, headache or abdominal distension.
Date: Nov. 5, 2013
Time: 20:30 pm
The patient said she went to toilet for bowel movement more than
10 times, with watery stool. She did not feel abdominal
distension or abdominal pains. She felt some palpitations with
some sweat. She was afraid of coldness. Check: her pulse was
wiry; her tongue was red, with greasy and white coating.
Date: Nov. 7, 2013
Time: 09:00 am
The patient said that she still suffered slight diarrhea.
Date: Nov.9, 2013 Time:
09:00 am
The patient did not suffer diarrhea any more. She did not feel
any abdominal pains, but she felt a little abdominal distension.
Date: Nov.14, 2013
Time: 09:00 am
The patient complained abdominal distension. Somethins it was
slight, while sometimes it was severe. Blood sugar, this
morning, on an empty stomach, 8.3mmol/L.
Bp 165/80 mmHg.
Date: Nov.17, 2013
Time: 09:00 am
The patient said, abdominal distension was better, but still
sometimes slight, sometimes severe. Her tongue was red, with
yellowish tongue coating. Her pulse was wiry and knotted. There
were pressing pains over her gastric areas.
Date: Nov.20, 2013
Time: 09:00 am
The patient said, there was no more abdominal distension. Bowel
movement was normal.
Date: Nov.22, 2013
Time: 09:00 am
Because of the expiration of her visa, Maryam asked to leave our
hospital today. She would take some herbal tea back home to
consolidate her treatment.
Condition at Discharge:
Patient discharged without dry mouth, polydipsia,
and polyuria. No headache and dizziness. Easy walking than
before, can self-shopping now, reduced swelling in lower limbs,
and no numbness in feet. Check: P 78 beats / min, Bp150/85mmHg.
Shiny complexion than before. Red tongue with thin yellow
coating, visible touching pulse. Taking "Carvedilol" and other
four kinds of drugs, insulin 14 u / day. Check blood urea
nitrogen (BUN) 3.82mmol/L,
uric acid 408 umol/L, CR 194umol/L.
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