Record of
Hospitalization
Name:
Rodaba Sex: Female
Age:
64 Marital
Status: Married
Nationality:
Muslim
Date of Admission: Dec. 10,
2010
Companion:
Her son
First Medical Record
Date:
Dec. 10, 2010 Time: 10:00
am
This 64-year-old lady
had been suffering from pains over his bone joints for 5 years,
developed into severe pains below her lumbar portion for 1 year.
The patient was hospitalized in our hospital for TCM treatment
at 7:40 am on December 10, 2010.
Essential for Diagnosis:
1. The patient had been
suffering pains over his bone joints for 5 years, developed into
severe pains below her lumbar portion for 1 year.
2. Five years ago, the
patient suffered joint pains over her whole general body without
any evident cause. At that time, the patient did not pay too
much attention to it, and the pains were not very severe,
therefore, she did not take any examinations and treatment. In
the recent one year, pains became severe, the lumbar portion and
her two lower limbs in particular. She went to the local
hospital for the MRI examinations on her neck and lumbar. The
report presented that she suffered from senile joint
degenerative disease. The doctor gave her some medicines for
calcium supplement and pain-killers, but the therapeutic effects
were not good.
3. When the patient came
to our hospital, she felt pains over her whole body joints and
bones, particularly pains over her lower limbs and
pressing-pains over her lumbar muscles. She felt very fatigued
when walking, with pains over her feet vola. The pains became
much severe after exercises. She had dry throat. She was easy to
be fatigued. She also had stomachaches. Appetite was good. Sleep
was just ok. Her spiritual activity was not good. She, at the
same time suffered constipation. Urination was ok. Her tongue
was slightly red with yellowish tongue coating. There was Thorn
of cricoid cartilage and base of tongue. Her pulse was weak and
wiry.
4. T: 36.2¡ãC R: 20
times/minute P: 58 times/minute BP: 124/80mmHg
5. The patient grew
normally. She was a little bit fat. Her spiritual activity was
not good. She had chronic disease complexion with painful facial
expressions. She had normal gait, but there were pains over her
feet volas and knees when walking.
6. The size and
formation of her thorax were normal. No enlargement with her
heart. Rhythm of her heart was 56 times per minute. Heart rate
was regular with no murmurs. Sound of
breathing in the lungs was clear, without any rhonchi.
Diagnostic Basis:
TCM:
The patient had suffered from pains over her bones and joints of
her whole general body, developed into severe pains below her
lumbar portion. Her lower limbs were weak and heavy. Both feet
volas were of pains and heat. Because the patient was at the
stage of high age and was sick for a long time, so the channels
in the body were affected. In addition, due to damp environment
in her residential place, the wind-heat dampness violated the
channels and network channels. When the channels were blocked,
then pains appeared. Long duration of disease violating the
channels damaged the qi and blood in the body. Because of this,
there were pains over the patient¡¯s whole general body. She
suffered dry throat and heat over her feet volas, which were due
to deficiency of the liver and kidneys. Therefore, according to
the syndrome of her tongue and pulse, her conditions could be
diagnosed as Bi syndrome.
Western Medicine:
The patient was 64 years old. She had pains over her bone joints
and muscles all over her general body. So, her condition could
be diagnosed as senile joint degenerative disease.
Diagnostic
Differentiation:
TCM:
The patient¡¯s condition is usually differentiated from wilting
disease. Wilting disease has the main symptoms of weak limbs and
muscle atrophy, usually without pains. So, it is easy to
differentiate them.
Western Medicine
diagnosis:
Her condition should be differentiated with rheumatoid
arthritis. Rheumatoid arthritis has the main symptoms of pains,
stiffness and deformation of the joints. And usually, the
symptoms are symmetrical. At the early state of the disease,
pains mainly happen over the joints. Therefore, there is no
difficulty to differentiate them.
First Diagnosis:
TCM: Bi syndrome.
Symptom identification:
wind-heat damp Bi syndrome as well as the deficiency of the
liver and kidneys.
Western medicine
diagnosis: Senile joint degenerative diseases.
Treatment strategy and
nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade¢òcare.
3. Diet of high protein
and low fat.
4. Companion.
5. Pathogenesis:
wind-heat damp Bi syndrome as well as the deficiency of the
liver and kidneys.
6. TCM strategy: to
remove wind and clear away heat, free the channels to arrest
pains as well as tonify the 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: Dec. 11,
2010 Time: 9:00 am
This morning, professor
Zhang paid a visit to the patient. She complained of pains over
her muscles and joints all over her general body for 5 years,
especially pains below her lumbar portion. She felt weak over
her lower limbs. When walking, she also felt pains over her
knees and feet volas. She had dry throat and abdominal
distention and pains. Her appetite was good, but sleep and
spirit were not good. She also had constipation. Urination was
good. Her tongue was red with yellowish tongue coating. Her
pulse was wiry and weak. According to the theory of TCM, her
condition was due to the wind-heat damp Bi syndrome as well as
the deficiency of the liver and kidneys. The treatment for her
condition was to remove wind and clear away heat, free the
channels to arrest pains as well as tonify the liver and
kidneys.
Date: Dec. 12,
2010 Time: 9:00 am
The patient said there
was no special improvement. Feedback of examination: Glucose:
3.47 mmol/L, K: 3.44 mmol/L, Na: 117 mmol/L, CL: 78.9 mmol/L.
Date: Dec. 14,
2010 Time: 9:00 am
The patient said there
was no evident improvement on the pains over her joints and
muscles. Dry throat and abdominal distention and pains were
better. Constipation improved. There were evident pressing pains
on her sternomastoid muscles. There was
no evident enlargement of lymph nodes over her neck. Her spirit
and appetite were good. Her tongue was red with yellowish tongue
coating. Her pulse was weak and wiry.
Date: Dec. 18,
2010 Time: 9:00 am
There was slightly
improvement on the pains over her general body. She still felt
dryness in her throat. Bowel movement and urination were normal.
There still existed burning heat at the bottom of her feet. Her
tongue was red with thin, yellowish and slightly dry tongue
coating. Her pulse was wiry and thready.
Date: Dec. 20,
2010 Time: 9:00 am
The patient said pains
over her sternomastoid muscles were evidently improved. At the
same time, pains over her muscles and joints were reduced
somewhat. Now, pains mainly happened on her left abdomen and
ribs as well as knees. Dry throat and heat over the bottom of
her feet still existed. Her tongue was red with yellowish and
slightly dry tongue coating. Her pulse was thready and wiry.
Date: Dec. 24,
2010 Time: 9:00 am
The patient¡¯s conditions
kept changing better. In recent days, her stomach was a little
bit painful than before. Her tongue was red with yellowish and
slightly dry tongue coating. The root of her tongue was bristle.
Her pulse was wiry and thready.
Date: Dec. 28,
2010 Time: 9:00 am
There were great
reduction on the pains over her upper body, and pains over her
lower limbs were reduced also. Dryness in her mouth and throat
and heat at the bottom of her feet were alleviated.
Date: Dec. 31,
2010 Time: 9:00 am
The patient said pains
over her sternomastoid muscles, both sides of her abdomen, her
neck and shoulders dispelled. Heat at the bottom of her feet was
reduced a lot. Dryness in her mouth and throat kept changing
better. One thumb-width above her belly button existed evident
pressing pains, particularly during the night. Pains over her
lumbar part and lower limbs did not improve much recently. Her
fingers were stiff at the moment of getting up; and after some
movement or exercise the fingers would be more flexible. There
were spontaneous jumping pains on the right side of her head.
Her spirit and appetite were normal. Sleep was good. Bowel
movement and urination were good. Her tongue was red with thin
tongue coating. Her pulse was slightly wiry.
Date: Jan. 4,
2010 Time: 9:00 am
Pains over her whole
general body were further alleviated. Spontaneous jumping pains
on the right side of her head disappeared. No more dryness in
her mouth. Heat at the bottom of her feet improved much. Stiff
fingers after getting up were better. Appetite and sleep were
normal. Bowel movement and urination were normal. Her tongue was
slightly red with thin and white tongue coating. Her pulse was
slightly wiry. Hair loss was severe since the winter season
came.
Date: Jan. 8,
2010 Time: 9:00 am
Professor Zhang paid a
visit to the patient. The patient complained of pains over her
lower legs and arms, especially during the night. Sleep was not
good. Pains over the inner side of her shank were reduced. She
felt hard to squat. Stiff fingers after getting up were better.
Her son said the patient¡¯s right ear was deaf for more than 7
years. Dryness still existed in her throat. Her tongue was
slightly red with thin tongue coating. Her pulse was wiry and
thready.
Date: Jan. 12,
2010 Time: 9:00 am
The patient said pains
over her lumbar part and arms as well as outer side of her lower
limbs were reduced. She could sleep for about 6 hours. Other
conditions liked days before without any special change.
Date: Jan. 16,
2010 Time: 9:00 am
Rodaba complained of
pains occurring especially in the night in the recent days.
Date: Jan. 20,
2010 Time: 9:00 am
The patient said pains
were not reduced evidently in recent days. Appetite and sleep
were just ok. Bowel movement and urination were normal.
Date: Jan. 24,
2010 Time: 9:00 am
Today, the patient said
pains over her upper limbs were reduced. Sleep was good, about 6
hours. Pains of her lower limbs were reduced a little bit.
Appetite and spirit were normal. Her tongue was slightly red
with thin and white tongue coating. Her pulse was slightly wiry.
Date: Jan. 28,
2010 Time: 9:00 am
The patient¡¯s conditions
were stable without evident improvement. Her appetite and spirit
were good. Her sleep was not good. Her tongue was red with thin
tongue coating. Her pulse was slightly wiry.
Date: Jan. 31,
2010 Time: 9:00 am
The patient¡¯s condition
was stable recently.
Date: Feb. 3,
2010 Time: 9:00 am
Sodaba decided to leave
the hospital tomorrow. After nearly two months¡¯ TCM
comprehensive treatment here in our hospital, she achieved some
improvement in her conditions. With the TCM treatment method of
removing wind and clearing away heat, freeing the channels to
arrest pains as well as tonifying the liver and kidneys, pains
over her whole general body were reduced somewhat. Night
sweating, heat at the bottom of her feet and abdominal pains
were improved much. Dryness in her throat still existed.
Appetite, spirit and sleep were normal. Urination and bowel
movement were normal also.
Doctor¡¯s advice after
leaving hospital:
1. Avoid wind-cold,
maintain good moods.
2. Take herbal medicine
back for continuing treatment.
