TCM China:

Record of Herbal Treatment Of Haifa from Saudi Arabia Improvement Of Scleroderma

       

         

 

Brief Summary: On Mar. 13, 2014, Haifa, came from Saudi Arabia who had been suffering skin impediment in traditional Chinese medicine (TCM) or  systemic sclerosis in the concept of western medicine, accompanied by tight skin. She had hot sensation over her gastric cavity and esophagus for 20 years. She was hospitalized in our hospital at 21:30 p.m. on March 12, 2014. She achieved significant improvement after 69 days TCM treatment.

 

Record of Hospitalization

Name: Haifa                                                       Sex: Female

Age: 38                                                              Marital Status: Married

Nationality: Saudi Arabia                                  Date of Admission: Mar. 12, 2014

Companion: Her brother

  

First Medical Record

Date: Nov. 26, 2011                                Time: 10:00 am

This 38-year-old lady had been suffering from skin impediment, accompanied by tight skin, hot sensation over her gastric cavity and esophagus for 20 years. The patient was hospitalized in our hospital for TCM treatment at 21:30 p.m. on March 12, 2014.

 

Essential for Diagnosis:

1. The patient had been suffering from tight skin, hot sensation over her gastric cavity and pharyngeal for 20 years. There were no food and medicine for her to get allergy response.

2. The patient complained of tight skin, slight stiffness. The color of her toe skin was bluish, especially after getting a cold. When we touched her skin, it was cold. The skin of her elbows and knees joints was dark and tight. She was rather skinny in the face. The skin was also tight in the face. She had high bridge of nose. There was hot sensation in her gastric cavity and esophagus, while no fullness or pains sensation. Sometimes she had vomiting. It was not easy to digest food. She felt dry throat and mouth. She preferred to warm drinks. Sometimes she had headache, dizziness and stuffy nose. And there were pains over her left waist and left lower limb. There was a mass with the size 4 2cm over her left supraclavicular fossa, but without pains. While around the mass there were pains. Appetite and sleeping were good. And her urination and bowel movement were normal.

3. T: 36.4C   R: 20 times/minute    P: 80 times/minute   BP: 106/80mmHg

4. The patient had normal growth, physique and spiritual activity. She had slightly skinny body. There was no yellow skin or yellow sclera over her whole body. There was no enlargement over her superficial lymph node. Her neck was soft. And her trachea was symmetrical. There were no blood stasis and pseudomembrane in her throat. The jugular vein was of no engorgement. Her chest was also symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of her heart was 80 times per minute. Heart rate was regular with no murmurs. Her abdomen was soft without pressing pains and rebound tenderness. There were no pathological reflections. There was no obvious sign of deformity over his spine. There was a mass with the size 4 2cm over her left supraclavicular fossa, but it was not moving when we touched it, and there was no pains. The result of meningeal irritation syndrome was (-).

 

Diagnostic Basis:

TCM: 1. Skin impediment

           2. Nausea

Western Medicine: 1. Scleroderma

                                 2. Reflux esophagitis

  

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade care.

3. Common diet.

4. Complete the related examination, three routine inspection, ECG and biochemical examination.

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

6. Acupuncture and massage: once a day

7. Avoid wind and cold, have a good mood and take care of diet. 

 

Date: March 14, 2014                                             Time:11:00 a.m.

Doctor Zhu Ming paid a visit to the patient. The patient complained tight skin, slight stiffness. The color of her toe skin was bluish, especially after getting a cold. When we touched her skin, it was cold. The skin of her elbows and knees joints was dark and tight. She was rather skinny in the face. The skin was also tight in the face. She had high bridge of nose. There was hot sensation in her gastric cavity and esophagus, while no fullness or pains sensation. Sometimes she had vomiting. It was not easy to digest the food. She felt dry throat and mouth. She preferred to warm drinks. Sometimes she had headache, dizziness and stuffy nose. And there were pains over her left waist and left lower limb. Appetite and sleeping were good. And her urination and bowel movement were normal. The tongue body shortened with yellow tongue coating. The pulse was wiry and unsmooth.

 

Date: March 15, 2014                                             Time: 9:00 a.m.

The patient said the symptoms were almost the same. There was slight acid regurgitation. This morning we got the result of the test. It showed: Lymph % 45%; TB 4.4 ; DB 0.5 ; SG 1.025; PRD +-.

 

Date: March 17, 2014                                             Time: 9:30 a.m.

The patient said there were stabbing pains over her neck and shoulders. And there were pains in her left waist and thigh. The tongue was thin with yellow and thick coating. There were spots of blood stasis in her tongue. The pulse was deep, wiry and unsmooth.

 

Date: March 20, 2014                                             Time: 9:30 a.m.

The patient said the hot sensation in her throat was relieved. And the time of hot sensation in her stomach was reduced. But sometimes she felt tightness when she had empty stomach. In the morning her hands had swelling. Her appetite and sleeping were good. And the urination and the bowel movement were normal. The tongue was slightly red with thick and yellow coating. The pulse was deep. 

 

 Date: March 23, 2014                                             Time: 9:00 a.m.

 The patient said there were waist pains and hands swelling. The other symptoms were the same.  

 

Date: March 26, 2014                                             Time: 9:00 a.m.

The patient said she had pains in her ribs. The doctor considered it may be relate with her period. The quantity of menstruation was less. The color was red. She felt the skin color of the hands and face skins was better. And the burning sense in the gastric cavity was obviously improved. 

 

Date: March 29, 2014                                             Time: 9:00 a.m. 

The patient said the temperature of four limbs was warmer. There still were the pains in her left ribs. There were pressing pains around the tendons of forearm chelidon. The pulse was slippery.

 

Date: April 01, 2014                                              Time: 9:00 a.m.

The pains around the tendons of forearm chelidon were obviously improved as well as the burning sense in her gastric cavity. She felt heavy in her left lower limb.

 

Date: April 04, 2014                                              Time: 9:30 a.m.

The patient said there was burning sense in the gastric cavity for one hour this morning, with no vomiting and pains. She felt dry mouth and throat. She preferred to warm drink.

 

Date: April 07, 2014                                              Time: 9:30 a.m.

There still was burning sense in the gastric cavity. And the four limbs were cold and the color of the skin was purple. Her stool was loose. There was ecchymosis in her tongue body with clear coating. The pulse was deep and wiry.

 

Date: April 11, 2014                                              Time: 9:30 a.m.

The burning sense in the gastric cavity had great improvement. And the temperature of her four limbs was increased. There was sweating in her back.

 

Date: April 16, 2014                                              Time: 9:30 a.m.

The body temperature was increased rapidly. And the temperature of fingers also was obviously increased. The pulse was floating with power.

 

Date: April 20, 2014                                              Time: 10:00 a.m.

The effect of the first treatment course was good for the patient. There is no discomfort. The vital signs of the patient were stable.

 

Date: April 24, 2014                                               Time: 10:00 a.m.

The patient felt the burning sense in the gastric cavity, so doctor adjusted the formula. Doctor asked her to pay attention to her diet. Eat smaller, more frequent meals to relieve the burning sense.

 

Date: April 30, 2014                                               Time: 10:00 a.m.

There was still burning sense in the gastric cavity. To avoid the symptoms getting serious, doctor adjusted the formula to strengthen her stomach.

 

Date: May 5, 2014                                             Time: 10:00 a.m.

The patient had obvious improvement. There is no discomfort. But the temperature of her fingers had no obvious change.

 

Date: May 10, 2014                                               Time: 10:00 a.m.

The patient felt the burning sense was better. But the color of skins was still obviously changed with the changing of the weather. The pulse was powerful.

Date: May 15, 2014                                              Time: 10:00 am

The condition of stomach was fine. But the temperature of finger was not good. It was hot in the upper part of the body, while cold in the lower part of the body. The pulse was deep and wiry. There is no dry mouth.

 

Date: May 25, 2014                                              Time: 10:00 am

The patient said the burning sense disappeared. Her appetite was good.

 

Date: May 31, 2014                                              Time: 10:00 am

The patient said that the burning sense in the stomach began again. The other conditions were getting better.

Date: June 5, 2014                                             Time: 10:00 a.m.

The patient felt there was slight distension in her abdomin.

 

Date: June 10, 2014                                              Time: 10:00 am

The abdominal distension disappeared without pains. But the temperature of hands was still no obvious change. The color of hands skins changed to purple when the weather changed.

 

Date: June 15, 2014                                              Time: 10:00 am

The patient said the burning sense was unstable. Sometimes she had the problem, sometimes the problem was relieved. When the problem attacked to her, she had stomachache and the burning sense under her sternum. And the color of fingers was changed to purple when the weather changed.

 

Date: June 18, 2014                                              Time: 10:00 am

The patient decided to leave our hospital today.

 

Doctors advice after leaving hospital:

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

2. Take herbal medicine back for continuing treatment.

3. Keep doing functional exercises.

More other successful treatment cases for scleroderma:

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