Profession:
housewife
Nationality: Saudi Arabia
Date
of hospitalization: June 22, 2006
Chief
complaints:
Wandering pains of the joints
throughout the whole body. Stiffness and swollen of wrist, knee
and ankle joints. The
condition
aggravated progressively.
History of present
illness:
The patient
complains that there were wandering pains throughout the whole
body three years ago. Swelling and stiffness of wrist and knee
as well as ankle joints. No headache and no dizziness. No
aversion to coldness and no hot fever. She was diagnosed with
rheumatoid arthritis and under the treatment at
the local hospital in her country. But the condition was not
improved, she even got muscular pains and spasm of the muscle.
On march of 2006, she was diagnosed with SLE. Due to the
medicine, the patient got central obesity with moon-shaped face,
and buffalo hump shaped back.
Her
condition
aggravated progressively and she was admitted to our red cross
hospital on July 22, 2006. Since she got the disease, the bowel
movement and urination are normal, but she gained over weight.
She
has no infectious
disease history of tuberculosis, hepatitis and typhoid. No
history of blood transfusion and
no allergy to any
medicine. No addiction of smoking and drinking.
She lives in a humid environment and has regular diet. No
addiction of smoking and drinking.
There is no similar case in her family. Her
parents are both healthy.
Physical
Examination:
Normal growth of
her body and over nutrition. Clear consciousness and
cooperative. No yellow stain of the skin sclera. No edema of the
superficial lymph nodes. Normal growth of his head and five
sense organs. Symmetrical size of the pupillae. Sensitive to the
light reflection. No
hyperemia
in the throat. No edema of the tonsil and
thyroid gland. The lips not turning blue. The
abdomen is flat and soft. No pressing pains and no rebound
tenderness. The peristaltic sounds normal. Swelling pains of the
lower limbs and the thumb joint.
Diagnosis of Western Medicine:
rheumatoid arthritis
SLE
Diagnosis of Chinese Medicine: Impediment (wind-cold-damp
impediment)
The treatment strategy: Dispel wind, quicken the network
vessels, eliminate cold, remove damp, boost qi and fortify
spleen, tonify the liver and kidney.
The patient is treated by herbal tea combined with acupuncture
and massage.
July 24, 2006
Calmness of sleep.
No discomfort after taking herbal tea.
July 25, 2006
Relieve of the joint pains. The pulse is deep and fine. Whitish
and thin tongue coating. Slightly reddish tongue body.
July 27, 2006
Diarrhea. Four times of the bowel movement
and the stool is sloppy. Slight abdominal pains. No aversion to
coldness. No fever. Nausea and vomiting. The pulse is fine and
rapid. Whitish and thin tongue coating.
codonopsis root 15g£¬
poria 15g£¬
magnolia bark 7g£¬
gordon euryale seed 15g£¬
etc.
July 29, 2006
Further relieve of the joint pains. Deep and fine pulse. The
tongue coating is thin and whitish. The treatment strategy is
mainly to dispel wind and quicken the network vessels.
ledebouriella 10g£¬
cooked rehmannia root 20g£¬
tangkuei 10g£¬
white peony root 15g£¬
etc.
August 2, 2006
Obvious improvement of the joint pains. No muscular spasm.
Swelling and distention of the anklebone. The abdomen is flat
and soft. Good sleep. The bowel movement and urination are
normal.
August 5, 2006
The joint pains of the whole body disappear basically. No
muscular spasm.
Slightly pains of the right
wrist. Slight swelling of the anklebone. Good spirit and
appetite. The bowel movement and urination are normal. Whitish
and thin tongue coating. The pulse is deep and fine.
atractylodes root 8g£¬
cooked rehmannia root 20g£¬
notopterygium root 10g£¬
tangkuei 10g£¬
etc.
August 8, 2006
No pains all over the body. No muscular spasm. Swelling and
distention of the
anklebone. Good spirit and
appetite. The bowel movement and urination are normal. Whitish
and thin tongue coating. The pulse is deep and fine.
August 10, 2006
The patient tells us that all the problems disappeared
basically. Good spirit and appetite.
The bowel movement and urination
are normal. Whitish and thin tongue coating. The pulse is deep
and fine. She will left hospital this morning, and keep on with
the herbal tea for one month¡¯s treatment.
¡¡
Please click here to download Wechat and scan the following QR code to add
Dr. XiXi.
Based upon our very
successful help to many rheumatism patients, rheumatism is now
one of the significant focuses of our hospital.
More
Rheumatoid Arthritis cases that we helped well:
