Brief Summary: On May 28, 2010, Helena from Namibia, who had suffered from SLE accompanied with abnormality of albuminuria, hematuria and fatigue for 2 years, was hospitalized in our hospital. She has achieved obvious improvement after 26 days TCM treatment here.

 

                                                                      Record of Hospitalization

Name: Helena                                                                                           Birthplace: Namibia

Sex: Female                                                                                               Profession: Teacher

Age: 38                                                                                                     Date of Admission: May 28, 2010

Nationality: Namibia                                                                                 Date of Record: May 29, 2010

Marital Status: Married                                                                            Onset Season: Grain Full

Complainer: The patient herself

　

Major complaint: abnormality of albuminuria, hematuria and fatigue for 2 years

Disease history: No history of hepatitis, trigeminal neuritis. No tuberculosis, schistosoma and other infectious diseases. No history of trauma and surgery. No allergic history of food such as soap, seafood, and medicines like penicillin. No history of blood transfusion. The history of preventive vaccination was unknown.

Personal history: She was born in Namibia. No addiction of wine drinking. She does not smoke. Her living environment is not bad. She is moderate in temper.

Family history: Her parents are both healthy.

　

First Medical Record

Date: May 29, 2010                                          Time: 15: 00 p. m.

Helena, a 38-year-old female, has suffered from SLE accompanied with abnormality of albuminuria, hematuria and fatigue for 2 years. She was hospitalized in our hospital for treatment at 15: 00 p. m. on May 28, 2010.

 

Essentials for Diagnosis:

1. The patient has suffered from SLE accompanied with abnormality of albuminuria, hematuria and fatigue for 2 years.

2. In August 2008, the patient was found out abnormality of albuminuria, hematuria by the regular examination of urine. She was diagnosed with SLE and lupus nephritis by renal biopsy and other examinations. She started to get treatment with Endoxam but without obvious improvement. She went to vomit after taking the medicine. Her sleep got worse and would wake up just three hours after sleeping. And it was difficult to sleep again. In 2002, the patient got hysterectomy due to ovarian cyst. She has suffered from asthma for 5 years.

Her present symptoms were as follow: Slightly hair loss, repeated ulcer in the mouth, some pains and distention in the right rib, fatigue, weakness in the body, upset, dry and bitter feeling in the mouth, bad appetite and sleep. The patient was easy to wake up after sleeping. She urinated one to two times at night. The bowel movement was normal.

3. T 35.6≧, R 20 times/minute, P 82 times/minute, BP 100/60mmHg.

4. She grew normally with common nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. Her body was in a positive posture and she was cooperative with clear mind.

5. There were three ulcers in the mouth and tenderness on the right rib. The patient felt painful in the region of the kidneys. Black tongue body and white tongue coating.

6. Accessory examination: No

Diagnostic Basis:

TCM: The patient's abnormality of hematuria was the symptom of the damage of the network vessels of the kidneys. The repeated ulcers in the mouth, vexation, dry and bitter mouth were the symptoms of the spreading and invasion of heat toxin. The damage of the network vessels of the kidneys and the invasion and spreading of heat toxin lead to the fatigue, weakness, bad appetite and sleep. So she was diagnosed with Turbidity of Kidneys.

Western Medicine: The patient has suffered from SLE accompanied with abnormality of albuminuria, hematuria and fatigue for 2 years. With the diagnosis of the local hospital, she was diagnosed with SLE and lupus nephritis.

Diagnostic Differentiation:

TCM: The patient's Turbidity of Kidneys should be differentiated from bloody stranguria. Bloody stranguria's main symptoms are blood in urine and dribbling urine. So they are not difficult to be distinguished.

Western Medicine: The patient's SLE should be differentiated from class of lupus syndrome which is due to medication. They have some similar symptoms, but the connection of SLE with medicines is not so obvious. And its clinic symptoms are slight. The clinic symptoms would disappear after stopping the medicines. So they are not difficult to be distinguished.

 

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Turbidity of Kidneys

Symptom identification: spread and invasion of heat toxin, damage of the network vessels of the kidneys

Western Medicine diagnosis: SLE and lupus nephritis

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Lower salt diet.

4. Pathogenesis: spread and invasion of heat toxin, damage of the network vessels of the kidneys.

5. Treatment strategy: cool the blood and reduce toxin, boost the kidneys and free the network vessels.

6. Herbal tea: Using the water to decoct it, four dosages in total, one dosage a day and drinking twice.

7. Acupuncture and massage once each day.

8. Perfect all the examinations.

 

Date: May 31, 2010                                          Time: 10: 00 a. m.

The examination showed that CH 8.1 mmol/l, TG 2.2 mmol/l, GLU 6.23 mmol/l. The routine urine examination: occult blood in urine (1+ ). And the routine blood examination: (-)    

　

Date: June 1, 2010                               Time: 10: 00 a. m.

The patient said that she stayed up all night because of the pains in the waist last night. There weren't any other complaints. The pressing pains in L2 and L4 were checked out which didn't affect the activities. But she asked for an examination of X ray. So the acupuncture was focused on the waist.

 

Date: June 1, 2010                               Time: 15: 00 p. m.

The test result of X ray showed that no abnormal changes in the lumbar spines and bones. So are the joints.

 

Date: June 6, 2010                              Time: 10: 00 a. m.

The patient said that the pains in the waist disappeared. The sleep was better. Her appetite was good. The uncomfortable feeling in the stomach was also gone. The only complaint was the burning sense in urination. The formula changed a little focusing on clearing heat and cooling blood, disinhibiting urination and clearing mind.

 

Date: June 11, 2010                              Time: 10: 00 a. m.

The burning sense in urination got better than before, but it still existed. The formula was the same. 5 dosages in total.

 

Date: June 16, 2010                              Time: 10: 00 a. m.

The general condition of the patient was stable, no other complaints.

 

Date: June 17, 2010                              Time: 10: 00 a. m.

The patient complained constipation for three days. We prescribed some herbs to drink with water.

 

Date: June 21, 2010                              Time: 10: 00 a. m.

The condition of hair loss was better. There was no ulcer in the mouth. The appetite and sleep were good. No bitter and dry feeling in the mouth. The pains and distension in the stomach disappeared. The symptoms of fatigue and weakness reduced a lot. There were no pains in the whole body except the slight pains of the inner side of the ankles. The burning sensation of urination was improved greatly. The bowel movement was normal. The tongue body was pink with thin and white coating. Because her father was ill, she asked to go back home.

 

Date: June 22, 2010                              Time: 11: 00 a. m.

Today the patient was to leave from our hospital. But the routine urine examination still showed: occult blood in urine (1+). So the doctor advised her to continue the treatment at home.