Brief Summary:
On Mar. 13, 2014, Haifa,
came from Saudi Arabia who had been suffering skin impediment in
traditional Chinese medicine (TCM) or systemic sclerosis
in the concept of western medicine, accompanied by tight skin.
She had hot sensation over her gastric cavity and esophagus for
20 years. She was hospitalized in our hospital at 21:30 p.m. on
March 12, 2014. She achieved significant improvement after 69
days TCM treatment.
Record of
Hospitalization
Name:
Haifa
Sex: Female
Age:
38 Marital Status: Married
Nationality:
Saudi Arabia
Date of Admission: Mar. 12, 2014
Companion:
Her brother
First Medical Record
Date:
Nov. 26, 2011 Time: 10:00
am
This 38-year-old lady
had been suffering from skin impediment, accompanied by tight
skin, hot sensation over her gastric cavity and esophagus for 20
years. The patient was hospitalized in our hospital for TCM
treatment at 21:30 p.m. on March 12, 2014.
Essential for Diagnosis:
1. The patient had been
suffering from tight skin, hot sensation over her gastric cavity
and pharyngeal for 20 years. There were no food and medicine for
her to get allergy response.
2. The patient
complained of tight skin, slight stiffness. The color of her toe
skin was bluish, especially after getting a cold. When we
touched her skin, it was cold. The skin of her elbows and knees
joints was dark and tight. She was rather skinny in the face.
The skin was also tight in the face. She had high bridge of
nose. There was hot sensation in her gastric cavity and
esophagus, while no fullness or pains sensation. Sometimes she
had vomiting. It was not easy to digest food. She felt dry
throat and mouth. She preferred to warm drinks. Sometimes she
had headache, dizziness and stuffy nose. And there were pains
over her left waist and left lower limb. There was a mass with
the size 4
¡Á2cm
over her left supraclavicular fossa, but without pains. While
around the mass there were pains. Appetite and sleeping were
good. And her urination and bowel movement were normal.
3. T: 36.4¡ãC R: 20
times/minute P: 80 times/minute BP: 106/80mmHg
4. The patient had
normal growth, physique and spiritual activity.
She had slightly skinny body. There was no
yellow skin or yellow sclera over her whole body. There was no
enlargement over her superficial lymph node. Her neck was soft.
And her trachea was symmetrical. There were no blood stasis and
pseudomembrane in her throat. The jugular vein was of no
engorgement. Her chest was also symmetrical. Sound of breathing
in the lungs was clear, without any rhonchi. Rhythm of her heart
was 80 times per minute. Heart rate was regular with no murmurs.
Her abdomen was soft without pressing pains and rebound
tenderness. There were no pathological reflections. There was no
obvious sign of deformity over his spine.
There was a mass with the size 4
¡Á2cm
over her left supraclavicular fossa, but it was not moving when
we touched it, and there was no pains.
The result of meningeal irritation syndrome
was (-).
Diagnostic Basis:
TCM:
1. Skin impediment
2. Nausea
Western
Medicine:
1. Scleroderma
2. Reflux esophagitis
Treatment strategy and
nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade
¢ò
care.
3. Common diet.
4. Complete the related
examination, three routine inspection, ECG and biochemical
examination.
5. Herbal tea: one
dosage a day and drink twice
6. Acupuncture and
massage: once a day
7. Avoid wind and cold,
have a good mood and take care of diet.
Date:
March 14, 2014
Time:11:00 a.m.
Doctor Zhu Ming paid a
visit to the patient. The patient complained tight skin, slight
stiffness. The color of her toe skin was bluish, especially
after getting a cold. When we touched her skin, it was cold. The
skin of her elbows and knees joints was dark and tight. She was
rather skinny in the face. The skin was also tight in the face.
She had high bridge of nose. There was hot sensation in her
gastric cavity and esophagus, while no fullness or pains
sensation. Sometimes she had vomiting. It was not easy to digest
the food. She felt dry throat and mouth. She preferred to warm
drinks. Sometimes she had headache, dizziness and stuffy nose.
And there were pains over her left waist and left lower limb.
Appetite and sleeping were good. And her urination and bowel
movement were normal. The tongue body shortened with yellow
tongue coating. The pulse was wiry and unsmooth.
Date:
March 15, 2014 Time:
9:00 a.m.
The patient said the
symptoms were almost the same. There was slight acid
regurgitation. This morning we got the result of the test. It
showed: Lymph % 45%¡ü;
TB 4.4
¡ý;
DB 0.5
¡ý;
SG 1.025; PRD +-.
Date: March 17,
2014 Time: 9:30 a.m.
The patient said there were stabbing pains
over her neck and shoulders. And there were pains in her left
waist and thigh. The tongue was thin with yellow and thick
coating. There were spots of blood stasis in her tongue. The
pulse was deep, wiry and unsmooth.
Date: March 20, 2014
Time: 9:30 a.m.
The patient said the hot
sensation in her throat was relieved. And the time of hot
sensation in her stomach was reduced. But sometimes she felt
tightness when she had empty stomach. In the morning her hands
had swelling. Her appetite and sleeping were good. And the
urination and the bowel movement were normal. The tongue was
slightly red with thick and yellow coating. The pulse was deep.
Date: March 23,
2014 Time: 9:00 a.m.
The patient said there
were waist pains and hands swelling. The other symptoms were the
same.
Date: March 26,
2014 Time: 9:00 a.m.
The patient said she had
pains in her ribs. The doctor considered it may be relate with
her period. The quantity of menstruation was less. The color was
red. She felt the skin color of the hands and face skins was
better. And the burning sense in the gastric cavity was
obviously improved.
Date: March 29,
2014 Time: 9:00
a.m.
The patient said the
temperature of four limbs was warmer. There still were the pains
in her left ribs. There were pressing pains around the tendons
of forearm chelidon. The pulse was slippery.
Date: April 01,
2014 Time: 9:00
a.m.
The pains around the
tendons of forearm chelidon were obviously improved as well as
the burning sense in her gastric cavity. She felt heavy in her
left lower limb.
Date: April 04,
2014 Time: 9:30
a.m.
The patient said there
was burning sense in the gastric cavity for one hour this
morning, with no vomiting and pains. She felt dry mouth and
throat. She preferred to warm drink.
Date: April 07,
2014 Time: 9:30
a.m.
There still was burning
sense in the gastric cavity. And the four limbs were cold and
the color of the skin was purple. Her stool was loose. There was
ecchymosis in her tongue body with clear coating. The pulse was
deep and wiry.
Date: April 11,
2014 Time: 9:30
a.m.
The burning sense in the
gastric cavity had great improvement. And the temperature of her
four limbs was increased. There was sweating in her back.
Date: April 16,
2014 Time: 9:30
a.m.
The body temperature was
increased rapidly. And the temperature of fingers also was
obviously increased. The pulse was floating with power.
Date: April 20,
2014 Time: 10:00
a.m.
The effect of the first
treatment course was good for the patient. There is no
discomfort. The vital signs of the patient were stable.
Date: April 24,
2014 Time: 10:00
a.m.
The patient felt the
burning sense in the gastric cavity, so doctor adjusted the
formula. Doctor asked her to pay attention to her diet. Eat
smaller, more frequent meals to relieve the burning sense.
Date: April 30,
2014 Time: 10:00
a.m.
There was still burning
sense in the gastric cavity. To avoid the symptoms getting
serious, doctor adjusted the formula to strengthen her stomach.
Date: May
5, 2014 Time: 10:00
a.m.
The patient had obvious
improvement. There is no discomfort. But the temperature of her
fingers had no obvious change.
Date: May 10,
2014 Time: 10:00
a.m.
The patient felt the
burning sense was better. But the color of skins was still
obviously changed with the changing of the weather. The pulse
was powerful.
¡¡
Date: May 15,
2014 Time: 10:00 am
The condition of stomach
was fine. But the temperature of finger was not good. It was hot
in the upper part of the body, while cold in the lower part of
the body. The pulse was deep and wiry. There is no dry mouth.
Date: May 25,
2014 Time: 10:00 am
The patient said the
burning sense disappeared. Her appetite was good.
Date: May 31,
2014 Time: 10:00 am
The patient said that
the burning sense in the stomach began again. The other
conditions were getting better.
¡¡
Date:
June 5, 2014 Time:
10:00 a.m.
The patient felt there
was slight distension in her abdomin.
Date: June 10,
2014 Time: 10:00 am
The abdominal distension
disappeared without pains. But the temperature of hands was
still no obvious change. The color of hands¡¯ skins changed to
purple when the weather changed.
Date: June 15,
2014 Time: 10:00 am
The patient said the
burning sense was unstable. Sometimes she had the problem,
sometimes the problem was relieved. When the problem attacked to
her, she had stomachache and the burning sense under her
sternum. And the color of fingers was changed to purple when the
weather changed.
Date: June 18,
2014 Time: 10:00 am
The patient decided to
leave our hospital today.
Doctor¡¯s advice after
leaving hospital:
1. Avoid wind-cold,
maintain good mood, and take care of diet.
2. Take herbal medicine
back for continuing treatment.
3. Keep doing functional
exercises.
¡¡
More other
successful treatment cases for
scleroderma:
Case-1
Case-2 Case-3
Case-4
Case-5
¡¡
