Name: Duan Jigui                                                    Sex: Male

Age: 52                                                                   Marital Status: Married

Nationality: China                                                   Date of Admission: Jan. 12, 2015

Companion: Alone

                               First Medical Record

Date: Jan. 12, 2015                                Time: 15:00 p.m.

This 52-year-old man had been suffering from pains of the joints for more than 12 years. His condition became severe for 3 months. The joints over his four limbs were stiff for 3 months, and this condition was severe for 10 days. He was hospitalized in our hospital as a patient gouty arthritis for TCM treatment at 15:00 p.m. on Jan. 12, 2015.

2. When Mr. Duan came to our hospital, the joints of his four limbs were stiff, especially the joints of his lower limbs. It is difficult to squat. Because of the stiffness over his knee-joins he just could bend his knee to walk. It is difficult to bend over his right elbow joint. In the morning his knuckles were stiff. When the weather was cold, the stiffness became severe. When the weather was hot or after exercises the stiffness slightly relieved. There were stabbing pains in the joints of his four limbs, especially in his toe-joints and his elbow joints. And the pains were severe at night, accompanied with burning sensation. Yet it was no red and swollen. There were deformation and dark skin over his joints. Sometimes he had tinnitus and blurred vision, with no sweating, dry and bitter mouth. His appetite and sleeping were good. And his urination and bowel movement were normal.

3. T: 36.5°C   R: 20 times/minute    P: 72 times/minute   BP: 130/80 mmHg

4. The patient had normal spiritual status with red facial expression. His movement was limited because of the stiff joints. There was no sign of yellow sclera or yellowish skin. There was hyperemia sign over this eyes. There was no enlargement over his superficial lymph node. His neck was soft with no resistance. His trachea was good and in the center. There were no swelling and pains over his throat. His chest was symmetrical. There was no enlargement of his thyroid gland. Rhythm of his heart was 72 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. His abdomen was soft, without any pressing pains, rebound tenderness or enclosed mass. There was no sign of deformity over his spine. There was deformation over his thumb joints. And his elbow joints could not be straight. There was slight bend of his knee-joints. The straight leg rising test showed it was positive. The meningeal irritation was negative. There were no pathological reflections, but the physiological reflections existed. His tongue was slightly dark with white and thin tongue coating. Her pulse was deep.

Diagnostic Differentiation:

TCM: Impediment Syndrome

Western Medicine diagnosis: Gouty arthritis

12 years ago, he was diagnosed with Gout by The No.1 People Hospital in Huaihua.

Treatment strategy and nursing: 

1. Routine care of traditional Chinese internal medicine. 

2. Grade Ⅱ care, companion, low purine diet.  

3. Complete the related examination, three routine inspection, the function of the kidneys and the liver. 

4. Herbal tea: one dosage a day and drink twice 

5. Acupuncture and massage: once a day 

6. Avoid wind and cold, had a good mood, take care of the diet.

Date: Jan. 13, 2015                                      Time: 9:00 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient this morning. This 52-year-old man had been suffering from pains of the joints for more than 12 years. His condition became severe for 3 months. The joints of his four limbs were stiff for 3 months and the condition was severe for 10 days. He was hospitalized in our hospital for TCM treatment at 15:00 p.m. on Jan. 12, 2015. When he came to our hospital, the joints of his four limbs were stiffness, especially the joints of his lower limbs. It is difficult to squat. Because of the stiffness over his knee-joints he just could bend his knee to walk. It is difficult to bend his right elbow joint. In the morning his knuckles were stiff. When the weather was cold, the stiffness became severe. When the weather was hot or after exercises the stiffness slightly relieved. There were stabbing pains in his four limb joints, especially his toe-joints and his elbow joints. And the pains were severe at night, accompanied with burning sensation. Yet it was no red and swollen. There were deformation and dark skin over his joints. Sometimes he had tinnitus and blurred vision, with no sweating, dry and bitter mouth. His appetite and sleeping were good. And his urination and bowel movement were normal. Keeping the same formula.

Date: Jan. 14, 2015                                      Time: 9:00 a.m.

The patient said his symptoms were not obvious changed. Keeping the same formula.

The patient said there were back pains. In the morning his fingers were of stiffness. And the fingers were cold when the doctor checked his fingers. His tongue body was dark with white and thin coating. This morning his pulse was slightly taut. The results of the test showed that his uric acid was 547. It was higher than the normal range. The doctor adjusted the formula.

Date: Jan. 18, 2015                                      Time: 9:00 a.m.

The patient said the movement of his four limbs was better than before, yet the joints were still stiff and he felt uncomfortable. And his finger-joints were still of stiffness in the morning, yet after exercises and hot compreing the stiffness relieved. The tongue body was dark with white and thin coating. To adjust his formula.

Date: Jan. 19, 2015                                      Time: 9:00 a.m.

The patient said there were no obvious changes. The symptoms were the same. To adjust the formula.

Date: Jan. 22, 2015                                      Time: 9:00 a.m.

The patient said the stiffness over his knees-joints obviously improved. Yet his finger-joints were still stiff in the morning. There were frequent urination at night, it was 2 to 3 times a night. His sleep was normal.

Date: Jan. 24, 2015                                      Time: 9:00 a.m.

The patient was rechecked the function of the kidney and the liver. Keeping the same formula.

The patient decided to leave the hospital tomorrow. Current condition: The stiffness of the joints of his four limbs relieved. Yet he still felt difficulty when he squatted. And the joints of his fingers were still stiff in the morning. He could straighten his right elbow joints. The pains over the joints of his left elbow relieved. The pains over his four limbs disappeared. The tinnitus and blurred vision both improved. His appetite and sleep were good. His urination and bowel movement were normal.