Brief Summary: On January 21, 2013, Zeng Jiujiu, from our Zhongfang County, who had been suffering pains over her upper limbs, legs and back for 2-3 years, was hospitalized in our hospital. She achieved some great improvement after11 days TCM treatment in our hospital with the help of herbal tea, acupuncture and massage.

 

Record of Hospitalization

Name: Zeng Jiujiu                                                                                                Sex: Female

Age: 55                                                                                                               Marital Status: Married

Nationality: China                                                                                              Date of Admission: Jan. 21, 2013

Companion: Alone

 

First Medical Record

Date: Jan. 21, 2013                               Time: 12:00 a.m.

This 55-year-old lady had been suffering pains over her upper limbs, legs and back for 2-3 years. The patient was hospitalized in our hospital for TCM treatment at 12:00 a.m. on January 21, 2013.

　

Essential for Diagnosis:

1. The patient had been hospitalized in our hospital for suffering from chronic pains over her back, legs and upper limbs for 3 years. She has no history of medicine allergy.

2. The patient complained that she suffered from pains over her back and legs for 2-3 years. There were stabbing pains over her lumbar part. She also felt painful over the back side of her head. She suffered menopause when she was 32 years old. She sometimes suffered hearing disorder. Functions of her gastrointestinal tract were abnormal.

3. T: 36.5＜C   R: 20 times/minute    P: 53 times/minute   BP: 120/80mmHg

4. The patient grew normally with standard body shape. Her spirit activity was good. She had chronic, sick and painful facial complexion. Movement of her limbs was limited. There was no symptom of congestion over her throat. Movement of her neck was normal. There was no enlargement of her lymph gland and thyroid gland. Rhythm of her heart was 60 times per minute. Sound of breathing in the lungs was clear, without any rhonchi. Her abdomen was soft, without any pressing pains and rebound tenderness. Temperature of her four limbs was a little bit low. There were pains over the joints of her limbs, but without any edema. Her pulse was deep.

 

Diagnostic Differentiation:

TCM:

The patient was worn out with age. Kidney Yang was not enough. Deficiency-cold was created inside her body, causing congealing cold and slowed blood flow. Channels inside were obstructed. When the channels were blocked, then pains appeared. Therefore, her condition belonged to the category of impediment. It was the cold - stagnation and blood - stasis type. Besides, the exogenous pathogenic factors invaded her body.

 

Western Medicine diagnosis:

1. The patient was worn out with age. She had history of sickness for many years.

2. Symptoms: lumbar pains, joints pains of her hands and legs. These conditions became severe when the temperature was reduced.

 

First Diagnosis:

TCM: Bi impediment.

Symptom identification: the deficiency of kidney-yang. 

Western medicine diagnosis: rheumatic arthritis

　

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Å care.

3. Common diet.

4. Pathogenesis: the deficiency of kidney-yang.

5. TCM strategy: warming the kidneys and yang, promoting the circulation of blood and freeing the channels

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

7. Acupuncture and massage: once a day

8. Applying for the examinations of blood routine, urine routine and stool routine; the examination of the functions of liver and kidneys, and other related examinations.

　

Date: Jan. 21, 2013                                             Time: 14:00 p.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient complained that she suffered pains over her upper limbs, legs and back for 2-3 years. There were obvious stabbing pains over her back. She also felt pains in the back side of her head. She had occasional hearing disorder. There was abnormity of her gastrointestinal functions. She often suffered stomachache. She suffered blurred vision for about 10 years. She had night urination for 3 times and bowel movement once a day. She had good sleep. She suffered menopause when she was at the year of 32. From the view of TCM and the patient¨s condition, Dr. Ming thought that the case of the patient could be diagnosed as impediment, due to the deficiency of kidney-yang, deficiency-cold generated inside, blood stasis and the obstruction of channels, which belonged to the type of cold - stagnation and blood - stasis. The treatment strategy for it would be to warm the kidneys and yang, promote the circulation of blood and free the channels.

 

Date: Jan. 22, 2013                                             Time: 10:00 a.m. 

After one day¨s TCM treatment, improvement was not so evident; but sleeps for the patient was much better.

 

Date: Jan. 23, 2013                                             Time: 10:00 a.m.

The patient felt slight improvement on her conditions. Temperature of her hand and feet were still low. Treatment should still be warming the kidneys and tonifying Yang as well as promoting the circulation of blood and removing blood stasis.

 

Date: Jan. 26, 2013                                             Time: 10:00 a.m.

Temperature of the patient¨s limbs was improved some. She still feared of cold and she felt heaviness over her whole general body. Therefore, in this period, treatment should be invigorating the spleen to eliminate dampness and warming the kidneys as well as freeing the channels. Her tongue body was thin, with cracks over the tongue sides. Her pulse was not that deep as before.

Date: Jan. 31, 2013                                             Time: 10:30 a.m.

The patient decided to leave the hospital today. After 10 days TCM treatment, there were no more pains over her back and legs. Movements of her joints were more flexible than before. Cold feeling was reduced.