TCM China:

Record of Herbal Treatment Of Zhou Hualiang, from China Improvement Of Gout

       

         

 

Brief Summary: On Feb. 27, 2015, Mr. Zhou hualiang, from the village of Lishan near our hospital, who had been suffering from gout, accompanied with swelling and hot joints for 3 months. His condition became worse and he could not walk for half a month. He was hospitalized in our hospital. He achieved great improvement after 11 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization 

Name: Zhou Hualiang                                     Sex: Male

Age: 49                                                          Marital Status: Married

Nationality: China                                         Date of Admission: Feb. 27, 2015

Companion: Alone 

First Medical Record 

Date: Feb. 27, 2015                                Time: 10:00 a.m. 

This 49-year-old man had been suffering from gout, accompanied with swelling and hot joints for 3 months. His condition became worse and he could not walk for half a month. He was hospitalized in our hospital as a patient with gout for TCM treatment at 10:00 a.m. on Feb. 27, 2015. 

Essential for Diagnosis: 

1. The patient had unknown dizziness and joint pains over his four limbs in 2012. He felt the joints of his four limbs were hot. And On Sep. 07, 2012, he went to the NO. 3 Peoples Hospital of Huaihua City for examination. The test results showed that the Uric Acid was 512 umol/l. After treatment, the UA was 477.9 umol/l, the clinic symptoms improved. While his condition was not cured completely. His condition was not stable, it was up and down. And he took the painkillers intermittently. The patient had attack 3 months ago. The joints were red and swelling and he had burning sensation over the joints of his four limbs. On Jan. 09, 2015, the NO. 3 Peoples Hospital diagnosed with left knee-joint retrograde degeneration. In order to get better treatment, he came to our hospital for TCM treatment. 

2. When the patient came to our hospital, he had serious pains over the joints of his four limbs, especially his knee-joints, ankle-joints and toe-joints. It was accompanied with red and swelling joints, obvious pains. He felt thirsty. His appetite and sleep were not good. And his bowel movement was constipated. The color of urine was yellow.

3. T: 36.2C   R: 20 times/minute    P: 78 times/minute   BP: 130/80mmHg 

4. The patient had normal growth, physique and spiritual status, yet acute disease face. He cooperated with doctors when the physical examinations were made. There was no yellow skin or yellow sclera over his whole body. The head had no deformity and masses. His nose was normal without stuffy nose and discharge. His lips was slightly red, and there was no congestion in his throat, no enlargement over his tonsil. His neck was soft with no resistance. There was no distention of jugular vein. The thyroid was normal. His trachea and chest were symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 78 times per minute. Heart rate was regular with no murmurs. His abdomen was soft with no pressing pains and rebound tenderness. There were pains over the joints of his four limbs. The joints of his left knee and his ankle were red and had swelling pains. It was difficult to walk and bend his knees. The meningeal irritation was negative. There were no pathological reflections, while the physiological reflections existed. The tongue body was reddish, the pulse was slippery and rapid.

Diagnostic Differentiation: 

TCM: 1. Impediment Syndrome

      2. Damp-heat accumulation  

Western Medicine diagnosis: Gout

Treatment strategy and nursing: 

1. Routine care of traditional Chinese internal medicine. 

2. Grade  care.  

3. Light diet, avoid wind and cold, have a good mood. 

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

5. Acupuncture and massage: once a day 

6. Complete the related examination. 

Date: Feb. 27, 2015                                      Time: 11:00 a.m.

Dr. Luo, doctor-in-charge, paid a visit to the patient this morning. The patient had serious pains over the joints of his four limbs, especially his knee-joints, ankle-joints and toe-joints. It was accompanied with red and swelling joints, obvious pains. He felt thirsty. His appetite and sleep were not good. And his bowel movement was constipated. The color of urine was yellow. The tongue body was reddish. The pulse was slippery and rapid. Dr. Luo made the treatment strategy and plan according his condition.

 

Date: Feb. 28, 2015                                      Time: 11:00 a.m.

The patient said the pains and burning sensation were almost the same. The color of urine was still yellow. His sleep was better.

Date: Mar. 01, 2015                                      Time: 10:00 a.m.

The patient said the swelling obviously improved.

Feedback of the examination: Blood test: white blood cell 13.55, neutrophil 9.51, monocyte 1.57 , eopiphile 0.81 , LYMPH 11.60 , Granr 70.60 , Hgb 171.00 . The function of liver and kidney: TB 56.8 , GLB , ORIC 417.00 , TG 2.42, LDC 3.52 .

Date: Mar. 03, 2015                                            Time: 10:00 a.m. 

The patient said his condition improved, the joint swelling disappeared, he could walk normally.

Date: Mar. 06, 2015                                            Time: 10:00 a.m. 

The patient said the swelling over his joints disappeared completely. And he could walk freely, while he still had pains over his joints.

Date: Mar. 09, 2013                                            Time: 10:00 a.m.

The vital signs of the patient were stable, the swelling of his joints disappeared, free to walk.

Date: Mar. 10, 2013                                            Time: 10:00 a.m.

The patient said the pains over his four limbs joints obviously reduced, especially his lower limbs. He got great improvement. And the swelling disappeared completely. The patient decided to leave the hospital today.

 

Doctors advice after leaving hospital: 

1. Avoid wind-cold. 

2. Take care of the diet. 

3. Take the herbal medicine back for consolidating the treatment.