Brief Summary:
On
May 14, 2010, the patient Paskal from Australia who had suffered
from lupus erythematosus
associated with
numbness and lack of energy in the body for 9 years, stiffness
of the left ankle and pains of the joints for 6 years
was
hospitalized in our hospital. He has achieved obvious
improvement after 21 days comprehensive TCM treatment with
herbal tea, acupuncture and massage in our hospital.
Record of Hospitalization
Name:
Paskal Sex:
Male
Age:
31 Profession: Engineer
Nationality:
Australia Marital Status:
Unmarried
Date
of Admission:
May
14, 2010 Date of Recording: May 15,
2010
Onset
Season:
the
Summer Solstice
Complainer:
The
patient himself
Major
complaint: He had numbness
and
lack of energy in the body for 9 years, accompanied by stiffness
of the left ankle and pains of the joints for 6 years.
Disease history: No history of hepatitis. No tuberculosis,
schist soma and other infectious diseases. No history of trauma
and surgery.
No allergic history
of medicines or food. No history of blood transfusion. The
history of preventive vaccination was unknown.
Personal history:
He was born in Australia and his living environment was dry. No
addiction of wine drinking. He smokes. He had a drug habit but
under control in the last 5 years.
Family history:
There was one family member suffering from cancer.
First
Medical Record
Date:
May 15, 2010 Time: 15:00 p.m.
Paskal, a
31-year-old male, has suffered from
lupus erythematosus
accompanied by
numbness and lack of energy in the
body for 9 years, and stiffness of the left ankle and pains of
the joints for 6 years. He was hospitalized in our
hospital for treatment at 15:00 p. m. on May 15, 2010.
Essentials for Diagnosis:
1.
The patient has suffered from lupus erythematosus
accompanied by
numbness
and
lack of energy in the body for 9 years, stiffness of the left
ankle and pains of the joints for 6 years.
2.
In 2001, the patient began to feel the numbness in the right
lower limb without obvious reasons. He went to a local hospital
and was diagnosed with lupus erythematosus. Then he got steroid
treatment and the symptoms disappeared three years later.
However he suffered from the previous problems again after
stopping the medicines for 6 months. So he restarted the steroid
treatment, but he did not note any obvious improvement.
Present symptoms:
There were numbness and lack of energy in the body. He had the
pains of the left knee and stiffness of the left ankle. He was
of aversion to cold and unable to walk promptly. Also there were
pains in the shoulders and back, migratory and intermittent
spasms. He felt dry mouth and liked to drink warm water with
feverish feeling in the palms and soles especially in the
morning. He could not sleep well at night and easily waked up in
the morning. Defection was normal but urination was yellow. He
had night sweating.
3. T
36.1℃，P
80
beats/minute, R 20
times/minute, BP 100/70 mmHg.
4.
He grew
normally with
common nutrition.
His mind was clear. He had an expression of chronic illness and
tiredness. His body was in a positive position and he was
cooperative with clear mind.
5. No thoracic
deformity. Sound of breath was bilaterally normal on
auscultation.
No sound of
pleural friction. Heart border was normal. No pathological
murmurs on auscultation.
6.
Assistant examination:
Not
provided.
Diagnostic Basis:
TCM:
The numbness and lack of energy in the body for 9 years was due
to stagnation of network vessels. His mouth was dry and he liked
to drink warm water. There were symptoms of feverish feeling in
the palms and soles, emaciation, yellowish urine, night sweating
due to yin vacuity and internal heat. So
he was diagnosed with invasion and spread of butterfly sore.
Western medicine: The patient has suffered from numbness of the
body for 9 years, and the stiffness of the left ankle and pains
of the joints for 6 years.
With the test
result
in local hospital he was diagnosed with
lupus erythematosus.
Diagnostic Differentiation:
TCM:
The patient's
invasion and spread of butterfly sore should be differentiated
from wilting pattern. The main symptoms of the wilting pattern
are atrophy and soft sinews and bones, futility of the body,
generally without pains of the joints and numbness in the body.
However the patient’s invasion and spread of butterfly sore
condition does not have the symptoms of atrophy and soft sinews
and bones, futility of the body, but with symptoms of dry mouth,
liking to drink water, night sweating, yellowish urine, dark
tongue body, thick tongue coating, slippery and string-like
pulse. So they are not difficult to be distinguished.
Western Medicine: The patient's
lupus erythematosus
should be differentiated from myasthenia gravis which usually
becomes worse after exercise and the condition is reduced when
the body is relaxed. So they are not difficult to be
distinguished.
First
Diagnosis:
TCM
diagnosis:
invasion and spread of butterfly sore
Pathogenesis:
obstruction of heat toxin in the network vessels, yin vacuity
Western medicine diagnosis:
lupus erythematosus
Plans
for treatment strategy and nursing:
1.
Routine care of traditional Chinese internal medicine.
2.
Grade = 3 \* ROMAN III care.
3.
Common diet.
4.
Rules of
treatment: Clear heat and harmonize construction, dispel wind
and free the network vessels, enrich yin and supplement the
kidneys.
5.
Herbal tea: Take four dosages of the herbal tea, one dosage a
day and drink twice.
6.
Acupuncture and massage: once a day.
7.
Have more medical examinations if necessary.
Date:
May 18, 2010 Time:
08:40 a.m.
The
examination showed no obvious abnormality. The weakness of the
limb became better and the whole body was relaxed after
acupuncture and massage yesterday.
Date: May 22, 2010
Time:
10:00 a.m.
The
patient said that the pains from the joints of the left limb
were improved obviously. There was muscular atrophy in his left
lower limbs and it was worse than the right lower limb. He was
advised to have more exercise on it.
Date: May 27, 2010
Time:
10:00 a.m.
The
patient told us that the weakness, numbness and pains in the
left lower limb got much better. The other condition was stable.
Date: May 31, 2010
Time:
10:00 a.m.
The
numbness of the left lower limb and the pains in the joints
disappeared. The weakness of the lower limbs improved obviously.
There was a little muscular stiffness. The formula changed
accordingly.
Date: June 5, 2010 Time:
10:00 a.m.
The
patient said that the strength of the left lower limb was
increased further. The muscular stiffness got better. He felt
dry mouth. The appetite was good. The formula was the same.
Date: June 10, 2010
Time:
10:00 a.m.
The patient said that the numbness of the left lower limb and
the pains in the joints were disappeared. The stiffness of the
left ankle improved obviously. The weakness of the left lower
limb and imbalance of walking straightened up. And the spasms
and pains in the back and shoulders were gone. The spirit and
appetite were good. The urination and bowel movement were
normal. The patient decided to leave hospital this day.
