Name: Luo Benqian                                                     Sex: Male

Age: 65                                                                        Marital Status: Married

Nationality: China                                                       Date of Admission: Jan. 26, 2015

Companion: Alone 

                                         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 response.

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.

Diagnostic Differentiation: 

TCM: Bone Impediment

Western Medicine diagnosis: 1. Hyperostosis over his right knee-joint

2. Sequel of cerebral infarction and hypertension

Treatment strategy and nursing: 

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.

Dr. Ming, 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.

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 leaving hospital: 

1. Avoid wind-cold. 

2. Take care of the diet.