¡¡

Brief Summary: On Apr. 13, 2009, Silva from India, who has suffered from SLE, accompanied with the symptoms of repeated fever, pains all over the body and butterfly spots on her face for 1 year and vomiting as well as diarrhea for 3 months, was hospitalized in our hospital. She has achieved obvious improvement after 76 days TCM treatment here.

 

Record of Hospitalization

Name: Silva                                                                                                         Birthplace: India

Sex: Female                                                                                                         Profession: Housewife

Age: 49                                                                                                               Date of Admission: Apr. 15, 2009

Nationality: India                                                                                                Date of Record: Apr. 15, 2009

Marital Status: Married                                                                                     Onset Season: Vernal equinox

Complainer: The patient herself

 

First Medical Record

Date: Apr. 15, 2009                                      Time: 19: 00 p. m.

Silva, a 49-year-old female, has suffered from SLE, accompanied with the symptoms of repeated fever, pains all over the body and butterfly spots on her face for 1 year and vomiting as well as diarrhea for 3 months. She was hospitalized in our hospital at 19: 00 p. m. on Apr. 15, 2009.

Essentials for Diagnosis:

1. The patient has suffered from the symptoms of repeated fever, pains all over the body and butterfly spots on her face for 1 year and vomiting as well as diarrhea for 3 months.

2. Last April, the patient began to have the symptoms of fever, pains all over the body and butterfly spots on her face without obvious reasons, so she went to a local hospital for treatment. Then her condition was gradually controlled and she was diagnosed with SLE. She took the western medicine all the time when she went home, but her condition was up and down. In the recent 3 months, the patient felt her condition became serious, accompanied with the symptoms of vomiting and diarrhea, so she came to our hospital for further treatment at 19: 00 p. m. on Apr. 15, 2009.

3. T 36.2¡æ, P 80 times/minute, R 20 times/minute, BP 130/70 mmHg

4. She grew normally with common nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. Her body was in a positive posture and she was cooperative with clear mind.

5. The patient felt obvious pains all over the body and tiredness. There were butterfly spots on her face, accompanied with the symptoms of occasional fever, nausea, vomiting and diarrhea.

6. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient has suffered from the symptoms of repeated fever, pains all over the body and butterfly spots on her face for 1 year and vomiting as well as diarrhea for 3 months. Obstruction of triple burner, disturbance of qi dynamic and spread of depressed fire result in vigorous fever. Disturbance of qi and blood causes the pains all over the body. Depletion and vacuity of the five viscera and phlegm-stasis brewing internally result in obstruction of spleen pulse. Then the patient could have the symptoms of poor food intake, vomiting and diarrhea, tiredness and weakness of the body, etc. From the aspect of TCM, all the symptoms are the manifestations of impediment pattern.

Western Medicine: The patient has suffered from the symptoms of repeated fever, pains all over the body and butterfly spots on her face for 1 year and vomiting as well as diarrhea for 3 months. She felt obvious pains all over the body and tiredness. There were butterfly spots on her face, accompanied with the symptoms of occasional fever, nausea, vomiting and diarrhea. Last April, she was diagnosed with SLE in the local hospital.

Diagnostic Differentiation:

TCM: The patient¡¯s impediment pattern should be differentiated from wilting pattern, which is mainly characterized by limp, weak and emaciated limbs with the numbness of the muscles. If the condition becomes serious, the patient can not grasp anything or stand. But usually the patient has no joint pains and these symptoms are mostly limited to the lower limbs. So they are not difficult to be distinguished.

Western Medicine: The patient¡¯s SLE should be differentiated from rheumatoid arthritis, which is accompanied with the symptoms of weakness, poor food intake, low-grade fever, numbness of the hands and feet. Then gradually the patient can feel swelling pains of the single joint or joints. So they are not difficult to be distinguished.

First Diagnosis:

TCM diagnosis: Impediment pattern

Symptom identification: blood heat exuberance, dampness damaging the intestines and stomach.

Western Medicine diagnosis: SLE

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade I care.

3. Under the care of a companion.

4. Common diet.

5. TCM treatment strategy: cool the blood, resolve toxin, quicken the blood circulation and free the channels and network vessels.

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

Main herbs used in the herbal tea: chenpi (tangerine peel), fuling (Poria), etc.

7. Acupuncture and massage: once a day.

8. Have more medical examinations if necessary.

 

Date: Apr. 17, 2009                                       Time: 9: 00 a. m.

There were butterfly spots on her cheekbones for 10 months, accompanied with the symptoms of fever, muscular pains all over the body, hair loss and repeated dental ulcer. She was diagnosed with SLE. The function of her stomach and intestines was seriously damaged due to taking the treatment of immunosuppressant and glucocorticoid for a long time. She had the symptoms of distending pains in the stomach duct, belching, acid reflux, scorching pains in the chest, abdominal distention, rumbling intestines, water diarrhea 4-5 times a day, tiredness, weakness, poor food intake and bitter mouth. Her tongue was red. Her tongue coating was yellow and slimy. Her pulse was weak and wiry. So the treatment strategy was to open with acridity, downbear with bitterness, harmonize the stomach, transform dampness, fortify the spleen and stop diarrhea. 

 

Date: Apr. 21, 2009                                      Time: 10: 00 a. m.

The patient still felt obvious distending pains in the stomach duct, belching and acid reflux. Besides, there were scorching pains in the chest and stomach duct. She could not sleep during the night. So the purpose of the treatment was to harmonize gastric acid, diminish inflammation and protect the stomach. The prescription was as follows: chishao (red peony root), danshen (salvia root), etc. 3 dosages in total.

 

Date: Apr. 24, 2009                                       Time: 9: 00 a. m.

There was some improvement of distending pains in the stomach duct, belching, acid reflux and scorching pains in the chest and stomach duct. Her bowel movement became soft and she had it twice a day. The abdominal distention also lessened. Her appetite became better and she could eat more food than before. Her tongue was red. Her tongue coating became thin and yellow. Her pulse was thready and wiry. Continue to take the same prescription. 3 dosages in total.

 

Date: Apr. 27, 2009                                       Time: 9: 00 a. m.

She still had the symptoms of distending pains of the stomach, belching and acid reflux, but her condition became better. Her appetite was also better. She had soft bowel movement twice a day. Her tongue was red. Her tongue coating was yellow in the middle. Her pulse was wiry. Continue to take the same prescription. 3 dosages in total.

Date: May 1, 2009                                       Time: 10: 00 a. m.

The function of her stomach was seriously damaged due to taking the treatment of immunosuppressant and glucocorticoid for 10 months. The relevant symptoms were improved after 10 days treatment of protecting the stomach, diminishing inflammation, harmonizing gastric acid, etc., but she still felt the stomach distention, belching, acid reflux, abdominal distention, etc. Her tongue was dark red. Her tongue coating was yellow in the middle. Her pulse was thready and wiry. The prescription was changed as follows: fuling (Poria), yinjin (curcuma tuber), etc. 3 dosages in total.

 

Date: May 4, 2009                                       Time: 10: 00 a. m.

Her condition was the same as before. Her appetite was generally ok.  The bowel movement was normal. Her sleep was not good and she could sleep for about 3-4 hours every night. The condition had the relation with Chinese wolfsbane invading the nervous system. The former prescription was changed a little. 3 dosages in total.

 

Date: May 7, 2009                                       Time: 10: 00 a. m.

The symptoms of the stomach distention, belching and acid reflux gradually lessened. There was some improvement of the muscular pains. Her spirit was better. She could eat more food, but there were the symptoms of abdominal distention and loose stool (1-2 times per day). Her tongue was red. Her tongue coating was yellow. Her pulse was thready and wiry. The prescription was changed as follows: dangshen (codonopsis root), foshou (buddha's hand), etc. 4 dosages in total.

 

Date: May 11, 2009                                      Time: 10: 00 a. m.

The stomach pains and distention obviously lessened. There was some improvement of her belching and acid reflux. She could eat more food than before. Her stool was the same. The red spots on her cheekbones gradually disappeared. There was obvious improvement of her dental ulcer. The hair loss became better. She felt muscular pains and numbness of the right buttock and thigh. Her tongue was dark red. Her tongue coating was thin and yellow. Her pulse was stronger than before. According to these symptoms, her condition was improved. Due to poor physique, the function of her stomach and intestines was not good. Professor Yang asked her to pay more attention to her diet. The former prescription was changed a little. 5 dosages in total.

 

Date: May 16, 2009                                      Time: 10: 00 a. m.

The symptoms of her stomach were gradually improved. Her urine and bowel movement both were normal. Her appetite was better. There was some improvement of her spirit. Her sleep was good. There was no other abnormity. Her tongue was dark red. Her tongue coating was thin and yellow. Her pulse was thready and wiry. Continue to take the same prescription. 5 dosages in total.

 

Date: May 21, 2009                                      Time: 10: 00 a. m.

The symptoms of the stomach distention and pains were further improved. The belching became better. Her food intake was increasing. Her spirit was better. The red spots on her cheekbones disappeared. Her dental ulcer and the pains of her limbs were obviously improved. Her urine and bowel movement were normal. Her tongue was dark red. Her tongue coating was thin and yellow. Her pulse was thready and wiry. Continue to take the same prescription. 5 dosages in total.

 

Date: May 26, 2009                                      Time: 10: 00 a. m.

The function of her stomach and intestines was obviously improved. The spirit became better and her food intake increased. The red spots on her cheekbones disappeared. Her hair loss, dental ulcer and the pains of her limbs were gradually improved. Her tongue was dark red. Her tongue coating was thin. Her pulse was thready and wiry. Continue to take the same prescription. 5 dosages in total.

 

Date: Jun. 1, 2009                                       Time: 10: 00 a. m.

There were the symptoms of pains in the throat, cough, headache and nasal congestion. Her food intake was not good as before. Besides, she felt the pains all over the body. Her tongue was dark red. Her tongue coating was slightly thick. Her pulse was thready, wiry and slippery. These symptoms were the manifestations of wind evil invading the lungs and wind toxin settling in the throat. So the treatment strategy for her was to course wind, diffuse the lungs, resolve toxin and disinhibit the throat. The prescription was changed as follows: chishao (red peony root), chenpi (tangerine peel), etc. 3 dosages in total.

 

Date: Jun. 4, 2009                                       Time: 10: 00 a. m.

The symptoms of nasal congestion, pains in the throat, pains all over the body, etc. were improved. Her cough obviously lessened. Her food intake was better. Her spirit was normal. The red spots on her cheekbones disappeared. Compared with before, the skin of the four limbs became bright and white. Her tongue was slightly dark. Her tongue coating was thin and yellow. Her pulse was thready and wiry. These symptoms were the manifestations of elimination of exterior pattern and existence of Chinese wolfsbane. So the treatment strategy was to cool the blood, resolve toxin, boost qi and support right. The prescription was changed as follows: danggui (tangkuei), huangqi (astragalus root), etc. 5 dosages in total.

 

Date: Jun. 9, 2009                                       Time: 10: 00 a. m.

She didn¡¯t have the symptoms of pains in the throat and cough. Her spirit and food intake were ok. Her sleep, urine and bowel movement were normal. Her tongue was dark red. Her tongue coating was thin and yellow. Her pulse was thready and wiry. The former prescription was changed a little. The treatment strategy was to cool the blood and resolve toxin. 5 dosages in total.

 

Date: Jun. 16, 2009                                      Time: 10: 00 a. m.

The patient had the symptoms of stuffiness of the stomach duct, nausea and one time of vomiting. The vomitus was the food residue in the stomach. Besides, she was averse to cold and felt the pains in the throat. Her body temperature was 37.7¡æ. Her throat was bloodshot. Her tongue was red. Her tongue coating was yellow. Her pulse was floating was slippery. Professor Yang suggested her to take some herbal products to treat her cold and pay more attention to the diet.

 

Date: Jun. 17, 2009                                      Time: 10: 00 a. m.

Her body temperature was normal after the previous treatment. There were no symptoms of stuffiness of the stomach duct, nausea, vomiting, etc. The pains in the throat obviously lessened. Her spirit and food intake were normal. Her tongue was dark red. Her tongue coating was slightly yellow. Her pulse was thready and slippery. Continue to take the same prescription.

 

Date: Jun. 20, 2009                                      Time: 10: 00 a. m.

Her spirit, food intake, urine and bowel movement were normal. Her sleep was good. There was no other abnormity. Her tongue was dark red. Her tongue coating was thin and yellow. Her pulse was thready and wiry. These symptoms were the manifestations of elimination of exterior pattern and existence of Chinese wolfsbane. So the treatment strategy was to clear heat, cool the blood, resolve toxin and support right. The prescription was changed as follows: huangqi (astragalus root), huanglian (coptis), etc. 7 dosages in total.

 

Date: Jun. 25, 2009                                      Time: 10: 00 a. m.

The patient felt headache, pains all over the body, aversion to cold, fever and discomfort all over the body. Her food intake was not good. Her body temperature was 37.4¡æ. Her tongue was red. Her tongue coating was yellow. Her pulse was slippery and slightly rapid. These symptoms were the manifestations of wind heat assailing externally, dampness encumbering the spleen and stomach. So the treatment strategy was to course wind, clear heat, transform dampness and harmonize the center. The prescription was changed as follows: huanglian (coptis), chuanxiong (ligusticum root), etc. 2 dosages in total.

 

Date: Jun. 29, 2009                                      Time: 10: 00 a. m.

The patient has suffered from butterfly red spots on her cheekbones, pains all over the body, hair loss and dental ulcer for 10 months and distending pains in the stomach duct, belching, acid reflux, scorching heat in the chest and stomach duct, bitter mouth, bloating sense of the stomach duct and abdomen, rumbling intestines and water diarrhea 4-5 times a day for 4 months. Besides, she had the symptoms of poor food intake and exhaust of essence-spirit. Her tongue was red. Her tongue coating was yellow and slimy. Her pulse was weak and wiry. After the comprehensive treatment of opening with acridity, downbearing with bitterness, harmonizing the stomach, transforming dampness, fortifying the spleen, stopping diarrhea, clearing heat, resolving toxin, cooling the blood and transforming the spots in combination with acupuncture and massage for 76 days, the red spots on her cheekbones disappeared. There was some improvement of the pains all over the body. The hair loss stopped and her dental ulcer was obviously improved. There were no symptoms of distending pains in the stomach duct, belching, acid reflux, abdominal distention, rumbling intestines, diarrhea, etc. Her food intake increased. Her spirit became better. So the patient decided to leave the hospital tomorrow.

¡¡