Brief Summary:
On
May 14, 2010, the patient Nicole from Australia, who suffered
from
Fibromyalgia Syndrome and
chronic urinary tract infections,
was hospitalized in our hospital. After about 29 days TCM
treatment, she achieved significant improvement.
Record of Hospitalization
Name:
Nicole Sex:
Female
Age:
23 Profession: Land
Agent
Nationality:
Australia Marital Status:
Unmarried
Onset
Season:
Grain buds
Date of Admission: May 14,
2010
Complainer:
The
patient herself Reliability: Reliable
Major
Complaint:
The
patient has suffered from pains of the joints and muscles of the
whole body for 5 years, and her condition has been aggravated
for the last 1 year.
Present Illness:
Five
years ago, there happened a car accident on the patient. After
that, she felt headache and pains of the joints and muscles of
the whole body, especially the shoulders, back and right knee
and ankle. She did
neurological exam, muscular tests, MRI, etc. in local hospital.
The results were normal. The local doctors suspected that she
suffered Fibromyalgia Syndrome, so
she was treated with western medicine (medicine was unknown).
The effect was no good. In April 2010, she took our herbal tea
which was mailed by our hospital; the medicine relieved
her pains on the muscles and joints.
When she came to our hospital, she had the symptoms of
muscular spasms, pains of the muscles and joints, especially the
shoulders, back and her ankles and knees. When she felt pains,
there would be accompanied muscular spasms and the feeling of
heat, swelling
and constrictive of systemic
joints. There was dull heaviness of the bilateral lower limbs.
Also, she complained headache, dizziness, and sometimes she had
tinnitus, cough, chest stuffiness and palpitations. She had dry
mouth, a bitter taste in her mouth and pharyngeal dryness. She
had frequent and painful urination and burning sense in the
urethra. Her bowel movement was normal. And the other condition
was good.
Disease History: Stomachache.
No
history of tuberculosis, hepatitis or other infectious diseases.
No operation history.
She
had traumatic history.
Preventive vaccination provided was unknown.
Marital History: Unmarried.
Menstrual History:
Her
menstrual onset was at the age of 14. Generally, her menstrual
period was 4-7 days every 28 or 30 days. Her last
menstruation was on April 23, 2010. She had
dysmenorrheal.
Family History:
No family history.
Personal History:
She was born in Australia, living in a dry environment. She
smoked. While no addiction to alcohol. She
had
a very pleasant nature.
Allergic History:
No
allergic history of medicine or food.
Physical Examination:
T
36.2℃，P
80
beats/minute, R 20
times/minute, BP 120/80 mmHg.
She grew normally
with
medium nutrition.
Her mind was clear. She had an expression of chronic illness
but natural
facial expression. She was cooperative in examination. Her skin
was moist. No jaundice in the sclera. No superficial lymph-node
enlargement. Bilateral pupils were round, equal in size, and
sensitive to light. Her head and
five sense organs were normal. No enlargement of
tonsil.
Neck touched softly,
windpipe was in the middle. No swollen thyroid. No
turgor
of jugular vein. No thoracic deformity. Sound of breath
was bilaterally normal on auscultation.
No
respiratory rales or pleural friction rubs. Heart border was
normal. Heart beat was 80 times/minute. Cardiac rhythm was
regular. No pathological murmurs on
auscultation. Abdomen
touched flat and soft. The liver and spleen were not palpable.
Renal area has knocking pains.
Bowel sound was normal.
No
deformity of
the
whole body bone. It has physiologic
reflex.
Pathologic reflex
has not been elicited. Her tongue was red with yellow and dry
tongue coating. Her pulse was thready.
Auxiliary Examination:
Not
provided.
First
diagnosis:
TCM
diagnosis: 1.
Impediment
syndrome; 2.
Stranguria
Pathomechanism:
Damp-heat obstructing the network channels, damp-heat pouring
down.
Rules of treatment:
Clear heat and disinhibit dampness, quicken the blood
circulation and free the network vessels.
Western medicine diagnosis: 1.
Fibromyalgia Syndrome;
2.
Chronic
urinary tract infections.
First
Medical Record
Time:
20:30 p. m. May 14, 2010
The
patient, Nicole, a 23-year-old female, has suffered from pains
of the muscles and joints for 5 years, and the condition has
been aggravated for 1 year. She was picked up by our staff at
Zhijiang Airport, and arrived in our TCM Hospital for treatment
at 20: 00 p.m. on May 14, 2010.
Essentials for Diagnosis:
1.
The patient has suffered from pains of the muscles and joints
for 5 years, and the condition has been aggravated for 1 year.
2.
Five years
ago, there happened a car accident on the patient. After that,
she felt headache, pains on the joints and muscles of the whole
body, especially the shoulders, back and right knee and ankle.
She did
neurological exam, muscular tests, MRI, etc. in local hospital.
The results were normal. The local doctors suspected that she
suffered Fibromyalgia Syndrome, so
she was treated with western medicine (medicine was unknown).
The effect was no good. In April 2010, she took our herbal tea
which was mailed by our hospital; the medicine relieved
her pains on the muscles and joints.
When she came to our hospital, she had the symptoms of
muscular spasms, pains on the muscles and joints, especially the
shoulders, back and her ankles and knees. When she felt pains,
there would be accompanied muscular spasms and the feeling of
hot, swollen
and constrictive of systemic
joints. There was dull heaviness of bilateral lower limbs. Also,
she complained headache, dizziness, and sometimes she had
tinnitus, cough, chest stuffiness and palpitations. She had dry
mouth, a bitter taste in her mouth and pharyngeal dryness. She
had frequent and painful urination and burning sense in the
urethra. Her bowel movement was normal. Her tongue was
red with yellow and dry tongue coating. Her pulse was thready.
3. T
36.2℃，P
80
beats/minute, R 20
times/minute, BP 120/80 mmHg.
4.
She grew
normally with
medium nutrition.
Her mind was clear. She had
an
expression of chronic illness but
natural facial
expression. She was cooperative in examination.
5. No thoracic
deformity. Sound of breath was bilaterally normal on
auscultation.
No
respiratory rales or pleural friction rubs. No pathological
murmurs on auscultation.
The liver and spleen were not touched. Abdomen touched flat and
soft.
6.
Assistant examination:
Not
provided.
Diagnostic Basis:
TCM:
The patient has suffered from pains on the muscles and joints
for 5 years, and the condition has been aggravated for 1 year.
Macronosia must affect the qi and blood. When she came to our
hospital, she had the symptoms of dry mouth, a bitter taste in
her mouth and pharyngeal dryness, her body was weak. Further
contraction of damp-heat evil which obstructing the network
vessels, muscles and joints, inhibition of qi-blood movement.
Damp-heat evil pouring down will cause painful urination,
frequent urination and urination with burning sense. All the
signals of
her tongue and pulse belong to the symptoms of damp-heat
obstructing the network vessels.
Western medicine: The patient has suffered from pains on the
muscles and joints for 5 years.
She did
neurological exam, muscular tests, MRI, etc., in local hospital.
All the results were normal. The doctor suspected the disease
was Fibromyalgia Syndrome.
Diagnostic Differentiation:
TCM:
It should be differentiated from wilting syndrome. The
characteristic of wilting syndrome are powerless joints and
limbs, even
muscular atrophy, there were no pains generally. So this disease
should be differentiated from wilting syndrome.
First
Diagnosis:
TCM
diagnosis: 1. Impediment pattern 2. Strangury
Pathogenesis:
Damp-heat obstructing the network vessels, damp-heat pouring
down.
Rules of treatment:
Clear heat and disinhibit dampness, quicken the blood
circulation and free the network vessels.
Western medicine diagnosis: 1.
Fibromyalgia Syndrome 2.
Chronic urinary tract infections
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.
Bland
diet.
5.
Rules of
treatment: Clear heat and disinhibit dampness, quicken the blood
circulation and free the network vessels.
6.
Herbal tea: Take four dosages of the herbal tea, one dosage a
day and drink twice.
7.
Acupuncture and massage: once a day.
8.
Have more medical examinations if necessary.
Date:
May 15, 2010
Time: 10:00 a.m.
The
patient
complained to Dr. Zhang that there were pains on the muscle of
the whole body, especially the shoulders, back and right knee
and ankle.
When she felt pains, there would be muscular spasms and the
feeling of heat, swollen
and constrictive systemic joints.
There was dull heaviness of bilateral lower limbs. Also, she
complained headache, dizziness, and sometimes she had tinnitus,
cough, chest stuffiness and palpitations. She had dry mouth, a
bitter taste in her mouth and pharyngeal dryness. She had
frequent urination, painful urination and burning sense in the
urethra. Her bowel movement was normal. Her tongue was
red with yellow and dry tongue coating. Her pulse was thready.
From TCM aspect, Dr. Zhang diagnosed
her illness as 1. Impediment pattern; 2. Strangury pouring
down. The
pathomechanism
is damp-heat obstructing the network channels, damp-heat pouring
down. The
rules for her treatment is to clear heat and disinhibit
dampness, quicken the blood circulation and free the network
vessels. Doctor's requirement is to
take four dosages of herbal tea of the same formula. One dosage
a day and drink twice.
Date:
May 16, 2010
Time: 10:00 a.m.
Examination: The results of
blood routine
examination, hepatic/renal
function, anti-streptolysin O,
ESR
(erythrocyte sedimentation rate) were normal.
Urinalysis: WBC + E4A Na 134.2mmol/L Ca
2mmol/L
ECG：
Normal
Date: May 18, 2010
Time:
10:00 a.m.
The
patient felt less pains on her muscles and joints. The condition
of dry mouth, a bitter taste in her mouth has improved. There
was no change of her frequent and painful urination. The
prescription was changed. 4 dosages in total.
Date: May 22, 2010
Time:
10:00 a.m.
The condition of
painful muscles and joints,
frequent and painful urination has improved obviously. The
prescription was the same as the one on May 18. 5 dosages in
total.
Date: May 27, 2010
Time:
10:00 a.m.
The patient
complained that the condition of painful muscles, frequent and
painful urination has improved, other conditions was good. The
prescription was the same. 4 dosages in all.
Date: May 31,
2010
Time: 10:00 a.m.
The patient's
condition got further improvement. The examination on May 25:
urinalysis, white blood cell +1. The prescription was the same.
5 dosages in total.
Date: June 5, 2010
Time:
10:00 a.m.
The
patient's urinalysis was normal. Her painful muscles and joints
got further improvement, her frequent and painful urination
improved obviously. The patient complained dry mouth. The
prescription was adjusted. 5 dosages in total.
Date: June 11, 2010
Time:
10:00 a.m.
The patients complained her painful shoulders and back got
obvious improvement. The pain in her right knee and right ankle
was disappeared. The swelling of the whole body and muscular
spasms has improved. The condition of dry mouth, a bitter taste
in her mouth and pharyngeal dryness has improved. Her frequent
and painful urination improved obviously. The patient decided to
leave hospital this day.
