Brief Summary: On April 19th, 2010, Lupusoru, who has suffered from rheumatoid arthritis and epilepsy, accompanied by the symptoms of running pains of the joints throughout the whole body for 4 years and poor sleep, was hospitalized in our hospital. After 28 days comprehensive TCM treatment here, the running pains of the joints have disappeared, and there is a big improvement in both his movement and sleep. He felt much less dizzy when he got up in the morning, sometimes it even disappeared. The frequency of his temporary disturbances of consciousness has been reduced from 7-8 times a day to 1-2 times a day.

 

Record of Hospitalization

Name: Lupusoru                                                                                                     Birthplace: Romania

Sex: Male                                                                                                               Profession: Business man

Age: 58                                                                                                                   Date of Admission: April 19, 2010

Nationality: Romania                                                                                              Date of Record: April 20, 2010

Marital Status: Married                                                                                          Onset Season: Grain Rain

Complainer: The patient himself

 

First Medical Record

Date: April 20, 2010                                      Time: 4: 00 a. m.

Lupusoru, who has suffered from rheumatoid arthritis, accompanied by the running pains of the joints throughout the whole body for 4 years and poor sleep, was hospitalized in our hospital. The running pains of the joints which were related to the changes in the weather all over the body. The pains were mainly pulling pains. The joints felt warm. He felt good in the warm and gentle weather. There was no swelling, no numbness in the limbs, no feeling of heaviness. His mouth was a bit dry. His sleep condition was not good, and he slept shallowly. His urination and stool were normal. His tongue body was a bit deep-red with thin and yellow coating. The pulse was wiry and soft.

Essentials for Diagnosis:

1. The patient had the running pains of the joints throughout the whole body for 4 years.

2. In 1995, the patient began to have pains in the left shoulder after getting wet in the rain. The pains had influenced his movement of the shoulder. He had taken acupuncture treatment in his local place, and had gotten some improvement. The pains had reduced. In 2007, the shoulder pains were aggravated. Slowly, it turned into the pains of the joints all over the body. There wasn't a diagnosis in his local place. In the last three years, he had a big working pressure. He often felt dizzy and heavy sense in the afternoon, sometimes had short confusion.

His health conditions when got to our hospital were bellow: The running pains of the joints which were related to the changes in the weather all over the body. The pains were mainly pulling pains. The joints felt burning. He felt good in the warm and gentle weather. There was no swelling, no numbness in the limbs, no feeling of heaviness. His mouth was a bit dry. His sleep condition was not good, and he slept shallowly. His urination and stool were normal.

3. T 36.3≧, R 20 times/minute, P 80 times/minute, BP 110/70mmHg.

4. He grew normally with common nutrition. His mind was clear. His body was a bit thin. No yellow appeared in the skin and sclerotic. No swelling of superficial lymph nodes. No goiter. No thoracic deformity.

5. 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. The abdomen is soft, no press pains and no rebound tenderness.

6. The patient had the pains on the joints of the shoulder when stretching or raising the arms. There were tenderness in the acromion and medial epicondyle of humerus. No deform and swollen joints in the spine and limbs. His tongue body was a bit deep-red with thin and yellow coating. The pulse was wiry and soft.

7. Accessory examination: None.

Diagnostic Basis:

TCM: After getting wet in the rain, the patient had had dampness evil which lead to obstruction of channels and network vessels. Once the channels and network vessels are obstruct, the joints and movement of the limbs will have pains. So from the aspect of TCM, it was impediment pattern.

Western Medicine: The patient had the running pains of the joints throughout the whole body for 4 years. The patient had the pains of the shoulder joints when stretching or raising the arms. There were tenderness in the acromion and medial epicondyle of humerus. He was diagnosed as rheumatoid arthritis.

Diagnostic Differentiation:

TCM: The patient's impediment pattern should be differentiated from wilting pattern. Wilting pattern is mainly characterized by limp, emaciated sinews and bones, with weakness of the muscles. However, impediment pattern is generally characterized by joint pains. So they are not difficult to be distinguished.

Western Medicine: The patient's rheumatoid arthritis should be differentiated from hyperplastic osteoarthritis.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Impediment pattern.

Symptom identification: obstruction of wind-damp, inhibition of the joints.

Western Medicine: Rheumatoid Arthritis

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade‰ care.

3. Low-fat and high-protein diet.

4. TCM treatment strategy: dispel wind, eliminate dampness, diffuse impediment and free the network vessels.

5. Herbal tea: one dosage a day and drink twice, 180ml every time.

6. Acupuncture and massage: once a day.

7. Have more medical examination if necessary.

 

Date: April 21, 2010                                     Time: 10: 00 a. m.

The patient had the running pains of the joints throughout the whole body for 4 years. His problems had appeared after getting wet in the rain in 1995. No diagnosis in his local place. He had taken acupuncture treatment in his local place, and had gotten some improvement. The pains had reduced. In 2007, the shoulder pains were aggravated. Slowly, it turned into the joints pains all over the body. The running pains of the joints which were related to the changes in the weather all over the body. The pains were mainly pulling pains. The joints felt burning. He felt good in the warm and gentle weather. There was no swelling, no numbness in the limbs, no feeling of heaviness. His mouth was a bit dry. His sleep condition was not good, and he slept shallowly. His urination and stool were normal. His tongue body was a bit deep-red with thin and yellow coating. The pulse was wiry and soft.

According to the patient's symptom, we prescribed a formula and made it into herbal tea for him. The formula mainly focused on the dispelling of wind, elimination of dampness, diffusing of impediment and freeing of the network vessels.

 

Date: April 22, 2010                                       Time: 14: 00 p. m.

The results of yesterday's tests:

Routine analysis of blood ------ normal

Routine analysis of urine ------ normal

Liver function test ------ normal

Kidney function test ------ normal

Blood sugar test ------ normal

Erythrocyte sedimentation rate ------ normal 

　

Date: April 26, 2010                                       Time: 14: 00 p. m.

The patient complained that all the joints didn't hurt, except the tenderness in the left medial epicondyle of humerus. He had a strong feeling of dizzy more than ten minutes after getting up from the bed. When he felt nervous, his head kept nodding, his facial expression changed, and he laughed loudly. The series of symptoms would last for about 20 to 30 seconds. From the point of TCM, the absence seizures are due to the phlegm confounding the orifices of the heart. According to this newly-found disease, we changed the formula for the first time. 5 dosages in all.

　

Date: May 1, 2010                                      Time: 10: 00 a. m.

The patient said that the pains of the joints all over the body disappeared. The movement of all the joints got obvious improvement. From today, the treatment strategy turned to transform phlegm, open the orifices, quiet the heart and spirit. A new formula was made. 5 dosages in all.

　

Date: May 6, 2010                                       Time: 10: 00 a. m.

The patient said that he felt less dizzy after getting up in the morning. The formula was the same as the last one.

　

Date: May 11, 2010                                       Time: 10: 00 a. m.

The patient complained that there were continuous improvements on the dizzy in the morning. The times of short confusion reduced. Other healthy condition was the same as before. The formula was changed a little.　

　

Date: May 16, 2010                                       Time: 10: 00 a. m.

After the 28 days of comprehensive treatment here including herbal tea, massage and acupuncture, the patient got a good recovery. The joint pains all over the body disappeared, the movement of joints were improved a lot. He felt much less dizzy in the morning; sometimes it even disappeared, the times of short confusion reduced from 7-8 times a day to 1-2 times a day. His appetite and sleep were good. His spirit was good too. He decided to leave our hospital in the afternoon.