Name: Mabroukah                                                                                              Sex: Female

Age: 40                                                                                                               Marital Status: Married

Nationality: Libyan                                                                                              Date of Admission: Sep. 26, 2012

Companion: Her Husband

First Medical Record

Date: Sep. 27, 2012                               Time: 9:00 am

This 40-year-old lady had been suffering from skin impediment, accompanied by tightness and swelling over the skin of her face and her four limbs for 10 years. In the past two month, her disease became severe, with tight feeling over her back skin. The patient was hospitalized in our hospital for TCM treatment at 19 on September 26, 2012.

Essential for Diagnosis:

1. The patient had been suffering from skin impediment, accompanied by tightness and swelling over the skin of her face and her four limbs for 10 years. In the past two months, her disease became severe, with tight feeling over her back skin.

2. When the patient came to our hospital, her facial skin and her four limbs were tight and swelling. Her back skin also was very tight. She felt dry in her mouth. She did not have difficulty in swallowing. The surface of her tongue was painful when she ate food; she was easy to be hungry. She felt burning sense in her esophagus; after took some western medicine, her burning sense was reduced somewhat. She also suffered pains over the joints of her shoulders, elbows, fingers, hips, knees and toes, especially her hip joints. Her hands and feet were cold, worsen during winter. She felt tiredness and blurred vision. She also suffered from hair loss and occasional tinnitus and sore throat. Her weight increased 5 kg.

3. T: 36.5¡ãC   R: 20 times/minute    P: 70 times/minute   BP: 108/66mmHg

TCM: Skin over the patient¡¯s face, four limbs and back were tight and swelling, and some parts had ulcers, therefore, it could be skin impediment. The patient was a little fat, and extremities of her limbs were swelling and tight. Her lower limbs were dropsical. These symptoms were due to exuberance of interior dampness. Dampness blocked the channels, causing pains over her whole body. Dampness obstruction caused bad flow of blood and qi, leading to qi stagnation and blood stasis. The skin lacked of nourishment of blood due to bad flow of the blood. Besides, damp-pathogen accumulated for long time, then turning into internal heat. So, we can see yellowish and greasy tongue coating. Deep pulse also was the symptom of exuberance of interior dampness. Therefore, her condition was diagnosed as skin impediment, due to interior dampness obstructing channels, qi stagnation and blood stasis, and lack of blood nourishment for the skin.

Western Medicine: Skin over the patient¡¯s face and four limbs were swelling and tight for 10 years. In the recent two years, skin over her back became tight. She felt dry in her mouth with mouth ulcers. She felt burning sense in her esophagus. Skin over her lips became atrophic. Ulcers also showed over extremities of her limbs. Most of her body joints were painful. Her condition had been diagnosed as systemic scleroderma at a France hospital.

First Diagnosis:

TCM: Skin impediment.

Symptom identification: Qi stagnation and dampness obstruction

Western medicine diagnosis: Systemic scleroderma.

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢ò care.

3. Common diet.

4. Pathogenesis: Qi stagnation and dampness obstruction

5. TCM strategy: promoting blood circulation to remove blood stasis, freeing the flow of qi and disinhibiting damp 

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

7. Acupuncture and massage: once a day

8. Have more medical examination if necessary.

Date: Sep. 27, 2012                                             Time: 9:00 am

Doctor Zhu Ming paid a visit to the patient. The patient complained that skin over her face and four limbs were tight. She felt dryness in her mouth. The surface of her tongue was painful when she ate food. She was easy to be hungry. She felt burning sense in her esophagus. Most of her body joints were painful. Hands and feet were cold, with purplish color. She felt tired and suffered hair loss and blurred vision. She often suffered tinnitus and sore throat. The elasticity of her skin decreased. Skin around her lips was rough and atrophic. Most parts of her toes and fingers suffered from ulcers. Pressing pains showed over many joints of her body. Both of her lower limbs were in edema. Movement of her upper limbs was limited because of pains. Her tongue was slightly red with yellowish tongue coating. Ulcers also showed over the surface of her tongue, with teeth marks. Her pulse was deep, thready and weak.

Eyelids and the lower limbs of the patient were slightly dropsical. Continued the previous prescription, adding shengjiangpi into it.

Date: Oct. 4, 2012                                              Time: 9:30 am

Skin over the face and upper limbs of the patient were not that much tighter than before. Swelling feeling over her finger tips was better. Burning sensation still happened over her throat and upper chest bone areas. Occasional pains over her whole body were better.

Date: Oct. 7, 2012                                              Time: 9:30 am

The patient said tightness over the skin of her face and upper limbs reduced. Edema of her lower limbs was also better than before. Burning sensation over her chest also was alleviated. Her private part was itchy, with much leucorrhea, showing green color. Adviced her to do Ultrasonic B examination. 

Date: Oct. 11, 2012                                              Time: 9:30 am

The patient said her pains were reduced obviously. Skin over her face and four limbs were softer than before. Edema still existed on her lower limbs. Burning feeling over her throat was better.

Date: Oct. 15, 2012                                              Time: 9:30 am

The patient said pains and burning feeling over her throat were alleviated a lot.  

Date: Oct. 18, 2012                                              Time: 9:30 am

The patient said itchy feeling over her private part was reduced. Tight feeling over her face and four limbs were reduced. Pains over her back happened occasionally. Burning sensation still existed over her throat, but less than before. Her tongue was slightly red with thin coating.   

Date: Oct. 25, 2012                                              Time: 9:30 am

The patient said there were no more burning feeling over her throat and back pains. No more edema over her lower limbs. Her throat was slightly red with thin and white coating. Ulcers reduced a lot. Her pulse was deep and thready. Left pulse was short and weak.

Date: Oct. 28, 2012                                              Time: 9:30 am

The patient said skin over her two hands and face were obviously softer than before. Hands and feet were warmer. Her tongue was slight red, with thin and yellowish tongue coating. There was still ulcer over her tongue tip. She did not feel dry or bitter in her mouth.

Date: Nov. 1, 2012                                               Time: 9:30 am

The patient said her back was painful. There was slightly burning sensation over her front chest. Pains happened over the ulcer surface of her tongue tip. Her tongue was slightly red with thin and yellowish coating. Her pulse was deep and thready.

Date: Nov. 4, 2012                                               Time: 9:30 am

Back pains and burning sensation over her front chest had already gone. Her tongue was slightly red with thin and yellowish coating. Her pulse was deep and thready. There still were ulcers over her tongue tip, but not painful. Her left pulse was not that short and weak as before.

Date: Nov. 7, 2012                                               Time: 9:30 am

The patient said she felt tightness over her fingers and lower limbs.

Date: Nov. 10, 2012                                               Time: 9:30 am

The patient said tight feeling over her fingers and lower limbs was reduced. When pressed on her lower limbs, the hollow of the skin was not obvious. Her tongue was slightly white with yellowish coating in the middle of her tongue. Her pulse was powerful than before.

Date: Nov. 13, 2012                                               Time: 9:30 am

Tight and swelling feelings over the patient¡¯s lower limbs were obviously better than before. Her fingers and toes still became blue when touching coldness. Inside part of her right foot was very painful. Her period was postponed. Her tongue was slight white, with yellowish tongue coatings.

Date: Nov. 16, 2012                                               Time: 9:30 am

The patient said her conditon was the same as days before. Pains on her feet were improved obviously. Her tongue was slightly white with yellowish and slightly dr coatings. Her pulse was deep and thready.

Date: Nov. 19, 2012                                               Time: 9:30 am

Pains over the patient¡¯s back happened occasionally. She had hiccups. Hands were warmer than before. Her tongue was slightly white with yellowish tongue coating. Tongue coatings were not dry. Her pulse was deep and thready.

Date: Nov. 22, 2012                                               Time: 9:30 am

The patient said no more pains on her back. Hands and feet were warmer than before. Other conditions just like days before. Today she came to her period, with no discomforts.

Date: Nov. 25, 2012                                               Time: 9:30 am

The patient said there were slight pains on her back and burning sensation on her front chest. Her tongue was slightly white with yellowish and dry coating. Ulcer showed on the tip of her tongue. She felt dry in her mouth. Her pulse was deep and thready.

Date: Nov. 28, 2012                                               Time: 9:30 am

The patient said no more back pains and burning sensation on her front chest. She said she felt much better than before. Tongue and pulse was the same as days before.

Date: Nov. 30, 2012                                               Time: 9:30 am

For the expiration of visa, Ms. Mabroukah asked to leave our hospital today. Till today, tight and swelling sensation over the skin of her face, four limbs and back were reduced obviously; when touching, much softer than before. When ate food, no more pains over her tongue surface. Burning sensation and back pains were alleviated a lot. Pains over the joints of her four limbs were gone. Her upper limbs could move freely. Hands and feet were warmer than before, with rosy color. Edema on her face and lower limbs was better. Ulcer over her tongue was improved a lot. Her tongue was slightly white with yellowish and greasy tongue coating. Her pulse was deep, thready and weak, but powerful than before.

Doctor¡¯s advice after leaving hospital:

1. Avoid wind-cold, maintain good moods.

2. Take care of the diet, with no spicy, hard and acid food.

3. Keep warm. Knead and rub hands and feet often to promote the circulation of blood.

4. Take herbal medicine back for continuing treatment.