Brief Summary: On April 27, 2015, Mr. Pan Rensheng, came from Zhongfang County, who had been suffering from gouty arthritis for more than 5 years and being severe for 7 days. He was hospitalized in our hospital. He achieved some improvement after 18 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

　

Record of Hospitalization

Name: Pan Rensheng                                                 Sex: Male

Age: 61                                                                      Marital Status: Married

Nationality: China                                                        Date of Admission: Apr. 27, 2015 

Companion: Alone

First Medical Record

Date: Apr. 27, 2015                            Time: 14:00 p.m.

This 61-year-old man had been suffering from pains over his body for more than 5 years, being severe for 7 days. He was hospitalized in our hospital as a patient with gouty arthritis for TCM treatment at 14:00 p.m. on Apr. 27, 2015.

Essential for Diagnosis:

1. The patient said he had the pains of the joints of his whole body after overwork 5 years ago. He felt distent pains of his joints, weakness, heavy and tired. He bought the medicine from the pharmacy by himself, the condition got better. Recent years, the pains repeatedly attacked. After the physical work, the pains got worse. After taking the rest, the pains relieved. When the pains appeared, he felt weak, sore, and the movement of joints limited, especially his upper joints. There was no allergy history of any food or any medicine.

2. When Mr. Pan came to our hospital, the pains attacked again 7 days ago. The pains ran over his body, especially his shoulder joints, and the joints movement was limited. After overwork, the pains got worse. When the weather was cold or in winter, the pains became severe. He felt tired. He felt sore and distent over his four limbs. His appetite was good. When he took the cold and spicy food, he had the symptoms of stomachache, abdominal distension and diarrhea. His urination was normal.

3. T: 36.2°C   R: 20 times/minute    P: 74 times/minute   BP: 90/60 mmHg

4. The patient grew normally. He was alert and cooperative. He had chronic sick facial complexion. There was  no sign of yellow sclera or yellowish skin. There was no enlargement on the superficial lymph node of his whole body.  Facial features were normal with masses. There were pressing pains over the top of his head and tempora bome. The pupillary reaction to light was sensitive. His neck was soft without resistance. His trachea was symmetrical. There was no enargement over his thyroid. The jugular vein was of no engorgement. His chest was symmetrical without deformity. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 74 times per minute. Heart rate was regular with no murmurs. His abdomen was soft with no pressing pains and rebound tenderness. There ws no sign of deformity over his spine. There were pressing pains over his should joints and around his spine. The meningeal irritation sign was negative. There were no pathological reflcetions, but the physiologival reflections existed. The tongue body was dark red with white and thin coating. The pulse was deep, string and slippery. 

　

Diagnostic Differentiation:

TCM:  Impediment

Western Medicine diagnosis:

1. Gouty Arthritis

2. Chronic Superficial Gastritis

3. Chronic Proctitis

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ care, Common diet.

3. Avoid wind-cold, regular daily life, have a good mood and take care of diet.

4. Completed the related examination, three routine inspection, the function of the kidneys and the liver, blood fat, blood sugar, anti-O, RF and IMX..

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

6. Acupuncture and massage: once a day

　

Date: Apr. 28, 2015                                            Time: 10:00 a.m.

Dr. Zhu Ming, doctor-in-charge, paid a visit to the patient. The patient complained that he had suffered from repeated muscle and joint’s pains over his whole body. He felt tired, weakness, sore and distension. He often took the medicine from the pharmacy, sometimes his condition improved and sometimes his condition regress. When he had overwork, his condition got worse, while his condition relieved after taking a rest. And the movement of joints limited, especially his upper limbs. 7 days ago, his joint-pains attacked again, and being severe. The pains runs over his whole body, especially his shoulder joints. He often felt abdominal distention. It affected his sleeping. The urination and bowel movement were normal. There were pressing pains over his shoulders and back. The movement of lifting his arms was normal. The tongue body was light red with white and thin coating. The pulse was string, slippery and slow.

　

Date: May 01, 2015                                   Time: 9:00 a.m.

The patient said the pains over his shoulders and back slightly relieved. Yet he still had the stomach distension. His appetite was poor. He could lift his arms normally. There were pressing pains over his shoulders and back. The tongue was light white with white and thin coating. The pulse was string.

　

Date: May 05, 2015                                   Time: 9:00 a.m.

The vital signs of the patient were stable. The patient said the back pains obviously improved. And he could turn his neck flexibly. And the stomach distension relieved. His appetite was better than before. His sleeping was normal. The urination and bowel movement were normal. While he still had the pressing pains over his shoulders.

　

Date: May 09, 2015                                   Time: 9:00 a.m.

The patient said his condition was stable, not changeable. Kept to take the previous formula.

 

Date: May 15, 2015                                   Time: 9:00 a.m.

The patient said the lumbago almost disappeared. And the pressing pains over his shoulders and back relieved obviously. He decided to leave the hospital. Took the herbal tea back for continuing treatment.