Brief Summary: On March 23, 2016, Mr. Pan Renmao, from Zhongfang County near our hospital, who had been suffering from burning pain over his lower back, knee-joints and hip joint for 3 years, being severe for 7 days. He was hospitalized in our hospital. His condition got great improvement after 16 days TCM treatment with the help of Acupuncture, Herbal tea and Tuina in our hospital.

　

                                                                                   Record of Hospitalization

Name: Mr. Pan Renmao                                                       Sex: Male

Age: 71                                                                                Marital Status: Married

Nationality: China                                                                Date of Admission: March 23, 2016

Companion: Alone

                         First Medical Record

Date: March 23, 2016                                    Time: 10:30 a.m.

This 71-year-old man had been suffering from burning pain over his lower back, knee-joints and hip joint for 3 years, being severe for 7 days. The patient was hospitalized in our hospital for TCM treatment as a patient with gouty arthritis at 10:30 a.m. on March 23, 2016.

Essential for Diagnosis:

1. The patient complained 3 years ago there was burning and swelling pain over his knee-joints without obvious inducement. He took some acupuncture and cupping treatment in local clinic. The symptoms improved, yet the pain repeated every year, and every time he took the acupuncture and cupping treatment. As time goes on, the acupuncture treatment could not help him. He took a physical examination, he was diagnosed with gout and he took the treatment. Yet he was not unsatisfied with the effect. And then he took the painkiller to relife the pain. The pain repeated attacks every year, he considered the side effect of painkiller, he came to our hospital for TCM treatment.

2. When the patient came to our hospital, he suffered the redness and swelling of knee-joits and distending pain of hip joint. Because of the pain he was restless whether sitting or standing, especially on the time after midnight. In the morning the pain slightly relieved. When ache is acuteness, the knee-joints became hot and red. There were pains over his lumbar vertebra, and the pain radiated to his right lower limb. He had dry mouth and he preferred the cold drink. He  also suffered from blurred vision, without palpitation. His appetite was normal. His sleeping was poor. The urination and bowel movement were ok.

3. T: 36.3＜C     R: 20 times/minute    P: 80 times/minute     BP: 140/70mmHg

4. The patient grew normally. He was alert and cooperative. He had chronic sick facial and flushing complexion. He was in compulsive position. 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 without masses and pressing pains. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. His ears were normal without secreta and pressing pain. His hearing was normal. His neck was soft without resistant, he could turn his neck flexibly. His windpipe appearance was good and in the center. There was no distention of jugular vein. There was no enlargement on his thyroid gland. His chest was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 75 times per minute. Heart rate was regular with no murmurs. We did not hear any pathologic sound. His abdomen was soft with no pressing pains, rebound tenderness and enclosed mass. There was no sign of deformity over his spine. Yet he was difficulty in walking. There was no obvious pressing pains around his lumbar vertebra. The knee-joints of his lower limbs was obviously red and swell with pressing pains. The function of stretching and bending over his knee-joints was limited. No pathological neuropathic positive. His tongue was red with yellow and thin coating. His pulse was rapid and string-like.

Diagnostic Differentiation:

TCM: Pains Impediment

Western Medicine diagnosis: 

1. Gouty Arthritis

2. Sciatica

3. Cervical Spondylosis

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Å care.

3. Slight diet, avoid wind-cold, regular daily life.

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: March 23, 2016                                           Time: 10:30 a.m.

Dr. Luo, doctor-in-charge, paid a visit to the patient this morning. The patient complained 3 years ago there was burning and swelling pain over his knee-joints without obvious inducement. He took some acupuncture and cupping treatment in local clinic. The symptoms improved, yet the pain repeated every year, and every time he took the acupuncture and cupping treatment. As time goes on, the acupuncture treatment could not help him. He took a physical examination, he was diagnosed with gout and he took the treatment. Yet he was not unsatisfied with the effect. And then he took the painkiller to relife the pain. When the patient came to our hospital, he suffered the redness and swelling of knee-joits and distending pain of hip joint. Because of the pain he was restless whether sitting or standing, especially on the time after midnight. In the morning the pain slightly relieved. When ache is acuteness, the knee-joints became hot and red. There were pains over his lumbar vertebra, and the pain radiated to his right lower limb. He had dry mouth and he preferred the cold drink. He  also suffered from blurred vision, without palpitation. His appetite was normal. His sleeping was poor. The urination and bowel movement were ok. His tongue was red with yellow and thin coating. His pulse was rapid and string-like. According to the above condition, Doctor Made the treatment strategy.

　

Date: March 24, 2016                                            Time: 10:00 a.m.

The patient said the condition was the same as last one, there is no obvious improvement.  

　

Date: March 25, 2016                                            Time: 10:00 a.m.

The patient said the distending pain over his knee-joints and hip joint improved. The redness and burning sensation over his knee-joints relieved. The other symptoms were the same.

Test reports:

， HDL0.73mmol/l◎.  According to the reports, doctor adjusted his formula.

　

Date: March 30, 2016                                            Time: 10:00 a.m.

The vital signs of the patient were stable. And his spirit status was obviously better. And the distending pain of his knee-joints relieved greatly. The redness and hot sensation disappeared. Yet the pain over his lumbar vertebra was the same. His dry mouth was better.  

　

Date: April 3, 2016                                            Time: 10:00 a.m.

The patient said the distending pain of his knee and hip joints almost disappeared. And the pain over his lumbar vetebra obviously improved. The sleeping was normal.

　

Date: April 08, 2016                                            Time: 9:00 a.m.

The patient said the distending pain of his knee and hip joints completely. Yet the redness of his knee-joints repeated, the heat did not clear completely. The pain over his lumbar vetebra almost disappeared. The doctor adjust the formula to clear his heat.

　

Date: April 09, 2016                                            Time: 9:00 a.m.

The patient siad the distending pain and redness over his knee-joints disappeared completely, the pain over his lumbar vetebra also disappeared. The other symptoms were recovery as well. The patient decided to leave the hospital today.