Name: Quang                                                                                                     Sex: Female

Age: 27                                                                                                              Marital Status: Unmarried

Nationality: Vietnamese                                                                                     Date of Admission: Aug. 19, 2010

Companion: Alone

First Medical Record

Date: Aug. 20, 2010                                Time: 11:00 am

This 27-year-old lady had been suffering from skin impediment, accompanied by swelling and thickening skin for 10 years and stiff hands and feet for 8 years. The patient was hospitalized in our hospital for TCM treatment at 20 pm on August 19, 2010.

Essential for Diagnosis:

1. The patient had been suffering swelling and thickening skin for 10 years and stiff hands and feet for 8 years.

2. The patient complained of pyrexia over the general body without any cause ten years ago and joint pains of the four limbs, then developed into red facial complexion, swelling and thickening skin, weak and stiff fingers as well as stiff feet and toes. Two years ago, she has swallowing problem. Her conditions were diagnosed as scleroderma in the local hospital. Before coming to our hospital, the patient had been taken the treatment of herbal tea shipped from our hospital for four months, and her conditions were alleviated somewhat.

3. When Quang came to our hospital, she suffered from thickening skin over almost the whole body. She felt very itchy over the skin. There was no sweat or little sweat out from the region of the hard skin. There was pigmentation of the skin, appearing different brown shades. The patient felt cold limbs. There were hot pains on the joints of elbows and knees. The hands and feet were of stiffness, especially showing on the fingers and toes. She had difficulties in swallowing with a sense of vomiting during meals. Her spirit was nervous. Sleep was not so good, but appetite was normal. In the recent 3 months, she had headaches at the temples, in need of pain killers to alleviate pains. Urination was good. Stool was soft.

4. T: 36.4¡ãC   R: 20 times/minute    P: 100 times/minute   BP: 120/80mmHg

5. The patient was of chronic and sick complexion with stiff facial expression and hard-waxy facial skin. Her spiritual activities were normal. She grew normally with skinny body.

6. The breathing sounds of the lungs were clear, with no pathological murmurs. There was no enlargement of the heart. The heart rate was regular and it was 100 times per minute with no pathological murmurs.

7. Physical check: The skin over the whole body was thickening with pigmentation of different brown shades. The joints of the fingers and toes were stiff. Except for the second joints of the thumbs, joints of the other fingers were bending. The upper limbs could be lifted up. Her lower limbs could not be bent down completely. The tongue body was thin. The tongue was slightly dark with thin and greasy tongue coating. The pulse was slow.

Diagnostic Basis:

TCM: The patient¡¯s conditions of cold limbs, watery stool, slightly dark tongue and slow pulse as well as systemic sclerosis for 10 years were due to Yang-insufficiency of spleen and kidney, specifically due to the vacuity cold. Due to the deficiency of Yang, transformation of Qi could not be promoted. Therefore, the movement of blood would be restrained, which led to the stagnation of nourishment and blood. Due to the stagnation of blood and nourishment, the fleshy exterior could not be nourished and the joints could not be disinhibited, which led to swelling and thickening skin as well as stiff joints. Therefore, the symptoms could be diagnosed as yang-deficiency of spleen and kidneys and stagnation of nourishment and blood.

Western Medicine: According to the local diagnosis and the symptoms of swelling and thickening skin for 10 years and stiff hands and feet for 8 years, her case could be diagnosed as systemic sclerosis.

Diagnostic Differentiation:

TCM: Skin impediment is usually differentiated from Fixed Bi or damp arthralgia. Damp arthralgia usually manifests such symptoms as joint pains of the limbs, pains and numbness of the bones and muscles of the extremities, the tumefaction and activity disabled. While skin impediment manifests progressive tumefaction and stiffness of the skin, and if it become worse, the Zang and Fu organs might be affected. So it is easy to differentiate them.

Western Medicine diagnosis: Systemic sclerosis should be differentiated with adult scleroderma. The skin damages of adult scleroderma usually start from the top of the head to the shoulders and back, with swelling and stiffness in the depth of derma. There is no regional pigmentation and manifestations of atrophy and hair loss, with the trend of self-recovery. While systemic sclerosis has such main symptoms as shiny hard skin of some parts of the body or over the whole general body, no sweat out from these pathological skin as well as hair loss. Therefore, there is no difficulty in differentiating them.

First Diagnosis:

TCM: Skin impediment.

Symptom identification: Yang deficiency of spleen and kidneys, the stagnation of nourishment and blood.

Western medicine diagnosis: Systemic sclerosis.

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢ò care.

3. Companion.

4. Common diet.

5. Pathogenesis: Yang deficiency of spleen and kidneys, the stagnation of nourishment and blood.

6. TCM strategy: fortifying Qi and nourishing spleen, warming the kidneys and reinforcing yang, nourishing blood and harmonizing nourishment as well as transforming stasis and alleviating impediment.

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

8. Acupuncture and massage: once a day

9. Have more medical examination if necessary.

Date: Aug. 21, 2010                                             Time: 10:00 am

Professor Yang Qingzhi paid a visit to the patient. The patient¡¯s skin became swelling and thickening for 10 years, developed into stiff hands and feet for 8 years. Her conditions were diagnosed as scleroderma in the local hospital. Before coming to our hospital, the patient had been taken the treatment of herbal tea shipped from our hospital for four months, and her conditions were alleviated somewhat. When Quang came to our hospital, she suffered from thickening skin over almost the whole body. She felt very itchy over the skin. There was no sweat or little sweat out from the region of the hard skin. There was pigmentation of the skin, appearing different brown shades. The patient felt cold limbs. There were hot pains on the joints of elbows and knees. The hands and feet were of stiffness, especially showing on the fingers and toes. She had difficulties in swallowing with a sense of vomiting during meals. Her spirit was nervous. Sleep was not so good, but appetite was normal. In the recent 3 months, she had headaches at the temples, in need of pain killers to alleviate pains. Urination was good. Stool was soft. The skin over the whole body was thickening with pigmentation of different brown shades. The joints of the fingers and toes were stiff. Except for the second joints of the thumbs, joints of the other fingers were bending. The upper limbs could be lifted up. Her lower limbs could not be bent down completely. The tongue body was thin. The tongue was slightly dark with thin and greasy tongue coating. The pulse was slow. According to the symptoms of the tongue and pulse from the view of TCM, professor Yang thought that the case of the patient could be diagnosed as skin impediment, due to yang deficiency of spleen and kidneys, the stagnation of nourishment and blood. The treatment strategy for it would be to fortify Qi and nourish spleen, to warm the kidneys and reinforce yang, to nourish blood and harmonize nourishment as well as to transform stasis and alleviate impediment.

Date: Aug. 22, 2010                                             Time: 10:00 am

The patient said headaches were dispelled. There was some alleviation about the intense sense of the skin of the lower limbs. She felt much more itchy after shower over the skin of the whole body, which might be due to her being unaccustomed to the climate of the new place. The doctor advised her to put the Pi kangwang ointment on the pathological skin. Other conditions were stable.

Date: Aug. 26, 2010                                             Time: 10:00 am

The patient felt her spirit better than before. The movement of her limbs was easier. Cold feeling of the four limbs was reduced somewhat. The swelling and thickening skin over the general body was slightly softer. Due to the function of the herbal tea, she sweated a lot. The tongue body was thin with slightly dark tongue surface and thin-white tongue coating. The pulse was thready.

Date: Sep. 1, 2010                                              Time: 10:00 am

The patient said she felt good. Skin over the whole body was softening and loosening with different degrees. Cold feeling of the four limbs basically disappeared. Sleep and appetite were good. The tongue body was thin. The tongue was slightly red with thin and white tongue coating. The pulse was thready.

Date: Sep. 6, 2010                                              Time: 10:00 am

Skin of the whole general body continued to become softening. In the recent two days, she waked up during the night because of the oppression in the chest. Other conditions were stable.

Date: Sep. 11, 2010                                              Time: 10:00 am

The patient felt better those days. Her conditions changes better day by day, except for occasional chest oppression. There was some improvement in her swallowing problem, but it was not so stable. Sometimes good, but sometimes bad. Appetite was good. Urination and stool were normal. The tongue body was thin. The tongue was slightly red with thin and white tongue coating. The pulse was thready.

Date: Sep. 16, 2010                                              Time: 10:00 am

The patient felt increasing improvement in her conditions. The skin over the whole body was much softer than before. The discomfort of oppression in the chest was dispelled. At present, she felt the swallowing function a little worse than before. Other conditions were stable.

Date: Sep. 18, 2010                                              Time: 10:00 am

Presently, the skin over her general body was softened, to a great extent. The pigmentation of the shades of brown became lighter than before. Sweating over the whole body was basically normal. There was no itchy sense any more. Cold feeling of the four limbs was dispelled and the limbs became warm. The pains on the elbows and knees were also dispelled. The swallowing problem was alleviated a lot. The motion of the body, like the range of keening down, was increased substantially. She was in a good mood. Sleep and appetite were good. The urination and stool were normal. The tongue was red with thin and yellow tongue coating. The tongue body was thin. The pulse was thready and weak. For the due date of her visa, she planed to leave the hospital this afternoon.

Doctor¡¯s advice after leaving hospital:

1. Avoid wind-cold, maintain good moods, and take care of the diet.