On
Feb. 27, 2015, Mr. Zhou hualiang, from the village of Lishan near our hospital,
who had been suffering from gout, accompanied with swelling and hot joints for 3
months. His condition became worse and he could not walk for half a month. He
was hospitalized in our hospital. He achieved great improvement after 11 days
TCM treatment with the help of herbal tea, acupuncture and massage in our
hospital.
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Record of
Hospitalization
Name: Zhou
Hualiang Sex: Male
Age: 49
Marital Status: Married
Nationality: China
Date of Admission: Feb. 27, 2015
Companion: Alone
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First Medical Record
Date: Feb. 27,
2015 Time: 10:00 a.m.
This 49-year-old man had
been suffering from gout, accompanied with swelling and hot joints for 3 months.
His condition became worse and he could not walk for half a month. He was
hospitalized in our hospital as a patient with gout for TCM treatment at 10:00
a.m. on Feb. 27, 2015.
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Essential for Diagnosis:
1. The patient had
unknown dizziness and joint pains over his four limbs in 2012. He felt the
joints of his four limbs were hot. And On Sep. 07, 2012, he went to the NO. 3
People¡¯s Hospital of Huaihua City for examination. The test results showed that
the Uric Acid was 512 umol/l. After treatment, the UA was 477.9 umol/l, the
clinic symptoms improved. While his condition was not cured completely. His
condition was not stable, it was up and down. And he took the painkillers
intermittently. The patient had attack 3 months ago. The joints were red and
swelling and he had burning sensation over the joints of his four limbs. On Jan.
09, 2015, the NO. 3 People¡¯s Hospital diagnosed with left knee-joint retrograde
degeneration. In order to get better treatment, he came to our hospital for TCM
treatment.
2. When the patient came
to our hospital, he had serious pains over the joints of his four limbs,
especially his knee-joints, ankle-joints and toe-joints. It was accompanied with
red and swelling joints, obvious pains. He felt thirsty. His appetite and sleep
were not good. And his bowel movement was constipated. The color of urine was
yellow.
3. T: 36.2¡ãC R: 20
times/minute P: 78 times/minute BP: 130/80mmHg
4. The patient had
normal growth, physique and spiritual status, yet acute disease face. He
cooperated with doctors when the physical examinations were made. There was no
yellow skin or yellow sclera over his whole body. The head had no deformity and
masses. His nose was normal without stuffy nose and discharge. His lips was
slightly red, and there was no congestion in his throat, no enlargement over his
tonsil. His neck was soft with no resistance. There was no distention of jugular
vein. The thyroid was normal. His trachea and chest were symmetrical. Sound of
breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was
78 times per minute. Heart rate was regular with no murmurs. His abdomen was
soft with no pressing pains and rebound tenderness. There were pains over the
joints of his four limbs. The joints of his left knee and his ankle were red and
had swelling pains. It was difficult to walk and bend his knees. The meningeal
irritation was negative. There were no pathological reflections, while the
physiological reflections existed. The tongue body was reddish, the pulse was
slippery and rapid.
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Diagnostic
Differentiation:
TCM: 1. Impediment Syndrome
2. Damp-heat
accumulation
Western Medicine
diagnosis: Gout
Treatment strategy and
nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade ¢ò care.
3. Light diet, avoid
wind and cold, have a good mood.
4. Herbal tea: one
dosage a day and drink twice
5. Acupuncture and
massage: once a day
6. Complete the related
examination.
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Date: Feb. 27, 2015
Time: 11:00 a.m.
Dr. Luo,
doctor-in-charge, paid a visit to the patient this morning. The patient had
serious pains over the joints of his four limbs, especially his knee-joints,
ankle-joints and toe-joints. It was accompanied with red and swelling joints,
obvious pains. He felt thirsty. His appetite and sleep were not good. And his
bowel movement was constipated. The color of urine was yellow. The tongue body
was reddish. The pulse was slippery and rapid. Dr. Luo made the treatment
strategy and plan according his condition.
Date: Feb. 28, 2015
Time: 11:00 a.m.
The patient said the
pains and burning sensation were almost the same. The color of urine was still
yellow. His sleep was better.
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Date: Mar. 01, 2015
Time: 10:00 a.m.
The patient said the
swelling obviously improved.
Feedback of the
examination: Blood test: white blood cell 13.55¡ü, neutrophil 9.51¡ü, monocyte
1.57 ¡ü, eopiphile 0.81 ¡ü, LYMPH 11.60 ¡ý, Granr 70.60 ¡ü, Hgb 171.00 ¡ü. The
function of liver and kidney: TB 56.8 ¡ý, GLB ¡ý, ORIC 417.00 ¡ü, TG 2.42, LDC 3.52
¡ü.
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Date: Mar. 03,
2015 Time: 10:00 a.m.
The patient said his
condition improved, the joint swelling disappeared, he could walk normally.
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Date: Mar. 06,
2015 Time: 10:00 a.m.
The patient said the
swelling over his joints disappeared completely. And he could walk freely, while
he still had pains over his joints.
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Date: Mar. 09,
2013 Time: 10:00 a.m.
The vital signs of the
patient were stable, the swelling of his joints disappeared, free to walk.
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Date: Mar. 10,
2013 Time: 10:00 a.m.
