3. T: 36.5＜C R: 18
times/minute P: 62 times/minute BP: 110/70mmHg
4. The patient grew
normally. She was alert and cooperative. She had chronic sick facial complexion.
There was no sign of yellow sclera or yellowish
skin and also no enlargement on the superficial lymph node of her whole body.
Facial features were normal with masses. Her neck was soft without resistance,
yet it is not flexible to turn on her neck. There were slight pressing
pains over her shoulders and back. The function of lifting her arms slightly
limited. Here trachea was symmetrical. There was no enlargement over her
thyroid. Sound of breathing in the lungs was clear, without
any rhonchi. Rhythm of her heart was 62 times per minute. Heart rate was regular
with no murmurs. Her abdomen was soft with no pressing pains and rebound
tenderness. There ws no sign of deformity over her spin. There was no obvious
edema. There were no pathological reflcetions, but the physiologival reflections
existed. The tongue body was light red with white and thin coating. The pulse
was deep, string, wiry and unsmooth.
Diagnostic
Differentiation:
TCM:
Impediment
Western Medicine
diagnosis:
1. rheumatoid arthritis
2. Meniere¨s syndrome
Treatment strategy and
nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade Å care,
Common diet, monitoring the blood pressure, once a day.
3. Completed the related
examination,
three
routine inspection, the function of the kidneys and the liver, blood fat, blood
sugar, anti-O, RF and IMX..
4. Herbal tea: one
dosage a day and drink twice
5. Acupuncture and
massage: once a day.
6.
Avoid
wind-cold, regular daily life, have a good mood and take care of diet.
Date: April. 13,
2015 Time: 10:00 a.m.
Dr. Ming,
doctor-in-charge, paid a visit to the patient. The patient complained that she
had suffered from repeated pains, accompanied with numbness for 6 years, being
severe for 3 months. And she often felt dizziness, weakness, chest oppression,
palpitation and shortness of breath. Her sleeping was not good, dreaminess. Her
appetite was not stable. For the pains of joints,
sometimes it was better, sometimes it was worse. In recent days, the tip of toes
had stabbing pains. There were the following symptoms, such as tinnitus,
forgetfulness, and aching in her lumbar and knees.
Body checked, it was difficult to make a fist because of powerless. There were
pressing pains over her knee-joints
and metacarpophalangeal joints. The tongue body was slight red with white and
thin coating. The pulse was string, wiry and unsmooth.
Date: April
16,2015 Time: 9:00 a.m.
The patient said the
pains over her four limbs relieved, and the numbness was better. And the
symptoms such as dizziness, palpitation and shortness of breath all improved.
Her appetite and sleeping were good. The urination and bowel movement were
normal. Body checked, the tongue coating was white and thin, the pulse was deep,
string and unsmooth.
Date: April 19,
2015 Time: 11:30 a.m.
The patient said The
pains improved greatly, and the numbness obviously relieved. The dizziness
almost disappeared.
Date: April 23,
2015 Time: 10:00 a.m.
The patient said the
pains over her four limbs and numbness disappeared completely. She could move
her joints flexibly. There were no dizziness, palpitation and shortness of
breath. She was in a good spirit status. Her appetite and sleeping
were good. The urination and bowel movement were normal. The tongue coating was
white and thin, the pulse was deep, wiry and powerful. The patient decided to
leave the hospital today. In order to consolidate the effect, the patient took
the herbal tea back.
Doctor¨s advice after
leaving hospital:
