Brief Summary:
On March 9, 2013,
Mr. S, from India, who had been suffering psoriatic arthritis,
accompanied by pains over his vertebral column for one year, was
hospitalized in our hospital. In the recent 3 months, his
condition became severe. He achieved great improvement after two
weeks TCM treatment in our hospital with the help of herbal tea,
acupuncture and massage.
Record of
Hospitalization
Name: Mr. S
Sex: Male
Age:
18 Marital Status: Unmarried
Nationality:
India Date of Admission: Mar. 9, 2013
Companion:
His mother
First Medical Record
Date: Mar. 9,
2013 Time: 10:00 a.m.
This 18-year-old boy had been suffering from psoriatic
arthritis, accompanied by pains over his vertebral column for
one year. The patient was hospitalized in our hospital for TCM
treatment at 19:30 p.m. on March 8, 2013.
Essential for Diagnosis:
1.
The patient had been suffering from psoriatic arthritis,
accompanied by pains over his vertebral
column for one year. His condition became severe in the
recent 3 months.
2. The
patient complained that he suffered from
stabbing pains over his vertebral column of his neck part,
chest part and lower back part after fatigue and sudden-changed
weather. When pains happened, there were reddish, edema and
heat. He went to a hospital in New Delhi for examination. His
condition was diagnosed as psoriatic arthritis and AS
(Ankylosing Spondylitis), according to his examination report
and his clinical manifestations. Doctors gave him some western
medicine for killing his pains, but the effect was not so good.
He used to do operations for 4 times for the problem of
hypospadias, but not succeeded. He had the medical history of
enteritis for 2 years.
3.
When Mr. S came to our hospital, she suffered from pains over
his neck, lumbar part and caudal vertebra，accompanied
by reddish, swelling and heat pains over his shoulders, knees
and chest part occurring 2-3 times every day and lasting for
about 1-1.5 hours, and then pains alleviated. He suffered
stabbing pains and felt burning and swelling sensation. When the
weather changed and he felt fatigued, his condition became more
severe. When pains happened, he felt hardness of his body and
felt hard to make movements. He felt dryness in his mouth and
had running nose, sore throat and coughing. He suffered
occasional gastric distension and gastric pains. His spirit was
not good. Appetite was bad. Sleep was normal. He had frequent
and urgent urination. When urinated, he felt painful and burning
sensation over his urethral meatus. He had night urination for 8
times per night, with less quantity each time. His bowel
movement was normal, with once a day.
4. T:
36.6°C R: 20 times/minute P: 97 times/minute BP: 124/84
mmHg
5. The patient grew
normally with standard body shape. His spirit activity was not
good. There was no enlargement of her lymph gland and thyroid
gland. Rhythm of his heart was 97 times per minute. Heart rate
was regular with no murmurs. Sound of
breathing in the lungs was clear, without any rhonchi. There
were percussion pains over his kidneys parts. There were
pressing pains over his liver parts. There were obvious pressing
pains over his shoulder muscles and slight pressing pains over
his knees. There was no swelling symptom over his knees. His
tongue was red, with thin and yellowish tongue coating and
cracks over the tongue surface. His pulse was thready and rapid.
Diagnostic Differentiation:
TCM:
The
patient had the main symptoms of reddish, swelling and burning
pains over his vertebral column and shoulders. He also felt
stiffness of his body. From the view of TCM, his condition
should be caused by pathogenic heat, wind and dampness invading
his channels and joints. Channels and joints were blocked, and
then pains happened. The stagnation of pathogenic wind could
cause fever; then, the patient felt stiff over his joints and
felt burning sensation when pains happened. Pathogenic wind
wanders a lot, so his upper limb joints were of severe pains and
the locations of pain points were unstable. He had frequent,
urgent and painful urination, which was caused by pathogenic
damp and heat wandering to the lower energizer. According to his
tongue and pulse symptoms, his condition should be arthritis and
heat stranguria.
Western Medicine diagnosis:
1.
Pains over his vertebral column and joints for 1 year, and
developed into severe condition for 3 months.
2.
There were percussion pains over his
kidneys parts. There were pressing pains over his liver parts.
There were obvious pressing pains over his shoulder muscles and
slight pressing pains over his knees.
First Diagnosis:
TCM:
1.
Arthritis
Symptom identification: impediment due to wind, dampness and
heat
2.
Heat stranguria
Symptom identification: damp heat sinking
Western
medicine diagnosis:
1. Psoriatic arthritis
2.
Lower urinary tract infection
3.
Second degree fatty liver
Treatment strategy and nursing:
1.
Routine care of traditional Chinese internal medicine.
2.
Grade
Ⅱ
care.
3.
Common diet.
4.
TCM strategy: dispelling wind and
eliminating dampness and freeing the channels as well as
relieving pains.
5.
Herbal tea: one dosage a day and drink twice
6.
Acupuncture and massage: once a day
7.
Have more medical examination if necessary.
Date: Mar. 10,
2013 Time: 09:00
a.m.
Dr. Ming,
doctor-in-charge, paid a visit to the patient. The patient
complained that there were stabbing pains over his neck, chest,
the lower back and vertebral joints. He felt burning sensation
when pains happened. He also felt painful and stiff over his
shoulders. He felt dryness in his mouth. He had running nose. He
also had sore and itchy throat. He coughed occasionally. He had
frequent, urgent urination. He had night urination 7-8 times.
The quantity of urine was less with yellowish color. His spirit
was not good. His appetite and sleep were normal. His tongue was
red with thin, greasy and yellowish tongue coatings. His pulse
was rapid and thready. There were pressing pains over his liver
part. The border of dull resonance of his liver was moving down.
His urinary meatus was reddish and painful. From the view of
TCM, Dr. Ming thought that the case of the patient could be
diagnosed as arthritis and heat stranguria, due to damp heat
being sinking. The treatment strategy for it would be to dispel
wind and eliminate dampness and free the channels as well as
relieve pains.
Date: Mar. 11,
2013 Time: 09:00
a.m.
The
patient said that he suffered burning joint pains once last
night around 21:00 p.m., and the pains lasted for almost 1.5
hours. He felt that the pains were less severe than before.
Running nose, itchy throat, sore throat and coughs were all
changed better. He still had urgent, frequent urination. He also
had burning sensation when urinated. Doctors advised him to
drink more water.
Date: Mar. 12,
2013 Time: 09:00
a.m.
The patient said pains
over his lower back part and chest part were reduced somewhat
yesterday. He suffered neck pains yesterday, lasting for about
40 minutes. He still had slightly dry cough. The symptoms of
frequent urination, urgent urination and odynuria were almost
gone. His tongue was red with thin, yellowish and greasy tongue
coatings. His pulse was thready and rapid.
Date: Mar. 15,
2013 Time: 09:00
a.m.
The
patient said that the symptoms of frequent urination, urgent
urination and odynuria were completely gone. He said there were
obvious pressing pains over his right shoulder. The pains went
from the inside of his forearm along the Lung Meridian of
Hand-Taiyin, lasting for around 20 minutes. There were neck
pains once, lasting for about 40 minutes. No pains happened over
his chest part and lower back part. He had dry cough with no
phlegm. His spirit was good. His appetite and sleep were normal.
Urination and bowel movement were normal. His tongue was red,
with thin, yellowish and greasy tongue coatings. His pulse was
thready and rapid.
Date: Mar. 17,
2013 Time: 09:00
a.m.
The
patient said he did not suffer any pains over his bone joints
these days. There was no special discomfort.
Date: Mar. 19, 2013
Time: 09:00 a.m.
The
patient said in the recent 3 days, he felt well. He did not feel
any pains over the bone joints of his whole general body. There
was no special discomfort.
Date: Mar. 22, 2013
Time: 09:00 a.m.
The
patient said pains over his vertebral joints, shoulders and
knees were gone. He felt very well right now. His spirit was
good. Appetite and sleep were normal. Urination and bowel
movement were normal. He decided to leave our hospital today.
Doctor’s advice after leaving hospital:
1.
Avoid wind-cold, maintain good moods, and take care of the
diet.
2.
Take herbal medicine back for continuing treatment.
3.
Avoid living damp area and do some proper exercise.
