Brief Summary:
On Feb
24, 2014, Nedezhdazuyece, came from Russia, who suffered from
arthritis. She had the wandering pains of the joins for 3 years.
The joints of the whole body had pains, and the pains were
wandering. Her neck and shoulders had pains, the pains were
worse if the weather was cold. The finger joints were painful
with burning sensation. She had headache in left side of his
head. Her arms always felt numbness, especially her right arm.
And her left rib had pains. Sometimes she had stomachache,
fever, nausea and hiccup. After the meal, the stomachache would
be relieved. And sometimes she had tinnitus. The color of urine
was slightly yellow. She had constipation, once every 3 to 4
days. Her mood was up and down a lot. She was hospitalized in
our hospital. She had great improvement after 19 days TCM
treatment.
Record of
Hospitalization
Name: Nedezhdazuyece
Sex: Female
Age:
52
Marital Status: Married
Nationality:
Russia
Date of Admission: Feb.24, 2014
Companion:
Nobody
First Medical
Record
Date: Apr. 17, 2014 Time: 11:00 am
Nedezhdazuyece,
male, 52 years old, had suffered from impediment pattern for 3
years. She was hospitalized in our hospital as a patient with
¡°wandering pains of the joints¡± for TCM treatment at 20:00 pm on
Feb. 24, 2014.
Essential for
Diagnosis:
1.
History of Disease:
The patient had the wandering pains of the joints for 3 years.
She was diagnosed with arthritis deformans at the local hospital
in 2010. She had chronic gastritis in 1998. She had chronic
pancreatitis and cholecystits in 2002. She had thyroid cyst in
2012, and she had ovary cyst in 2013.
2. When the patient
came to our hospital, she had the wandering pains of the joints
for 3 years. The joints of the whole body had pains, and the
pains were wandering. Her neck and shoulders had pains, the
pains were worse if the weather was cold. The finger joints were
painful with burning sensation. She had headache in left side of
his head. Her arms always felt numbness, especially her right
arm. And her left rib had pains. Sometimes she had stomachache,
fever, nausea and hiccup. After the meal, the stomachache would
be relieved. And sometimes she had tinnitus. The color of urine
was slightly yellow. She had constipation, once every 3 to 4
days. Her mood was up and down a lot.
3. T: 36.5¡ãC R: 20
times/minute P: 80 times/minute BP: 112/74mmHg
The patient had
normal growth, physique and spiritual activity, while with
chronic disease face. She cooperated with doctors when the
physical examinations were made. There was no enlargement over
her superficial lymph node. The pupils were round and
approximately equal in size. The pupillary reaction to light was
sensitive. The two eyeballs were slightly propped. The thyroid
was enlarged without pressing pains. The back of her neck had
nodules, and there were obvious pressing pains. When doctor
pressed the left nodule, she had headache in right side of her
head. The 1 and 2 chest vertebral body had obvious pressing
pains. To examine her heart and lungs, the result showed (-).
Her abdomen was soft. There were obvious pressing pains in her
gastral cavity, but without rebound tenderness. There were
pressing pains from the second lumbar vertebra to the first
sacral vertebra. The straight leg rising test showed that the
result of her left leg was positive. The results of figure of
¡°4¡± test were positive in both of her legs. There was no sign of
deformity over her spine and four limbs. There were no
pathological reflections, but the physiological reflections
existed. Her tongue body was thick with white and thin coating.
The pulse was taut and slippery. According to her right pulse
condition, she had deficiency of spleen qi, and the pulse was
weak with deep-pressing, while her left pulse condition was
powerful and strong.
4. Examination: No.
Diagnostic Basis:
TCM:
impediment pattern
Western Medicine:
arthritis deformans
Treatment strategy
and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade
¢ò
care.
3. Common
diet.
4. To
apply for the three routine inspections, and the related
examinations: the function of kidneys and liver, ESR, rheumatoid
factors, anti-O, etc.
5. Herbal
tea: one dosage a day and drink twice
6. Acupuncture
and massage: once a day
7. Avoiding from
wind and cold, regulating living timetable, relaxing mind and
adjusting the diet.
Date: Feb. 26,
2014 Time: 9:00 a.m.
Dr. Ming,
doctor-in-charge, paid a visit to the patient. The patient
suffered from the wandering pains of the joins for 3 years. The
joints of the whole body had pains, and the pains were
wandering. Her neck and shoulders had pains. The pains were
worse if the weather was cold. The finger joints were painful
with burning sensation. She had headache in left side of her
head. Her arms always felt numbness, especially her right arm.
And her left rib had pains. Sometimes she had stomachache,
fever, nausea and hiccup. After the meal, the stomachache would
be relieved. And sometimes she had tinnitus. The color of urine
was slightly yellow. She had constipation, once every 3 to 4
days. Her mood was up and down a lot. Body check up: The two
eyeballs were slightly propped. The thyroid was of enlargement
without pressing pains. The back of her neck had nodules, and
there were obvious pressing pains. When doctor pressed the left
nodule, she had headache in right side of her head. The 1 and 2
chest vertebral body had obvious pressing pains. To examine her
heart and lungs, the result showed (-). Her abdomen was soft.
There were obvious pressing pains in her gastral cavity, but
without rebound tenderness. There were pressing pains from the
second lumbar vertebra to the first sacral vertebra. The
straight leg rising test showed that the result of her left leg
was positive. The results of figure of ¡°4¡± test were positive in
both of her legs. There was no sign of deformity over her spine
and four limbs. There were no pathological reflections, but the
physiological reflections existed. Her tongue body was thick
with white and thin coating. The pulse was taut and slippery.
According to her right pulse condition, she had deficiency of
spleen qi, and the pulse was weak with deep-pressing, while her
left pulse condition was powerful. Dr. Ming diagnosed the
disease should be arthritis.
¡¡
Date: Feb. 27,
2014 Time: 9:00 a.m.
This morning we got
the results of the examination: Blood-R: WBC 3.6¡Á109
/L; Urine-R: Vc
£«3;
PRO£«£;
Stool-R: (-) ; Blood-LF: DB 1.6 umol/L; SPS: (-); HDL 0.51
mmol/L¡ý;
2- Hbdh 70 u/L
¡ý.
ESR:21 mm/h
¡ü;
Anti-O (-); rheumatoid factors:(-). The leukocyte was lower than
normal. ESR was slight fast.
Date: Feb. 28,
2014 Time: 9:00 a.m.
The patient said she
still had nausea this morning. There were much more sleeping.
The other symptoms were the same.
¡¡
Date: Mar. 4,
2014 Time: 9:00 a.m.
The patient said she
still had pains. Sometimes he had waist pains. But the sour
regurgitation and nausea disappeared. Her tongue was dark red
with white and thin coating. The pulse was taut and slippery.
The right pulse condition was the same. But the left one is
better. Doctor adjusted the formula.
Date: Mar. 5,
2014 Time: 9:00 a.m.
The patient said she
had headache, and she had hot sensation on her head, while her
feet were cold. Her tongue was reddish with yellow and thin
coating. The pulse was floating, taut and rapid. Her body
temperature was 37.2¡æ.
Doctor asked to do the blood routine examination. The doctor
prescribed the Radix Isatidis granules (one pack once, three
times a day).
Date: Mar. 5,
2014 Time: 15:00 p.m.
The result of blood
routine examination was normal. The patient said she was
allergic to the antibiotics, so she refused to take the medicine
Chlorphenamine maleate capsules.
Date: Mar. 6,
2014 Time: 9:00 a.m.
The patient said she
got cough with yellow phlegm, but without fever. There was no
headache. She did not mind the cold. The tongue was reddish with
white coating. The pulse was floating and taut. Doctor adjusted
the formula for her cough and phlegm.
Date: Mar. 9,
2014 Time: 9:00 a.m.
The patient said her
cough had been relieved. And the back pains were improved. But
she still felt tired without power. The tongue was red with
white and thin coating. The pulse was deep and wiry.
Date: Mar, 11,
2014 Time: 9:00 p.m.
The patient said she
had pains in her 12nd rib-side when she took deep breathing. But
there were no obvious pressing pains. Last night she had
sweating at night. And she felt her body was hot, but in her
palms and soles she felt cold. Doctor considered the patient¡¯s
age, and she had menstrual disorder. It should be the symptoms
of menopause. So doctor asked the patient to keep good mentality
and do some proper exercises.
Date: Mar, 14,
2014 Time: 9:00 p.m.
The patient decided
to leave our hospital. Conditions at discharge: The joint pains
had been improved. And there were no burning sensation and pains
in her finger joints. And her headache and stomachache were
obviously relieved.
Doctor¡¯s advice
after leaving hospital:
Avoid wind and cold, regulate living timetable, relax mind and
adjust the diet.¡¡
