TCM China:

Record of Herbal Treatment Of Ms. Liang Zhuangmei, from China Improvement Of Rheumatoid Arthritis

 

 

 

 

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Brief Summary: On April 25, 2015, Ms. Liang Zhuangmei, from Zhongfang County, who had been suffering       from repeated pains over the joints of her whole body for more than 10 years, being severe for 3 days. She was hospitalized in our hospital. Her condition got great improvement after 11 days TCM treatment with the help of Acupuncture, Herbal tea and Tuina in our hospital.

                                                                                   Record of Hospitalization

Name: Ms. Liang Zhuangmei                               Sex: Female

Age: 58                                                               Marital Status: Married

Nationality: China                                               Date of Admission: April 25, 2015

Companion: Alone

First Medical Record

Date: April 25, 2015                                    Time: 11:00 a.m.

This 62-year-old woman had been suffering from repeated pains over her four limbs for 6 years, being severe          for 3 months. The patient was hospitalized in our hospital as a patient with rheumatoid arthritis for TCM treatment      at 12:00 a.m. on April 12, 2015.

Essential for Diagnosis:

1. The patient had repeated pains, accompanied with numbness for 6 years, being severe for 3 months. There was     no history of trauma, no allergy history of any medicine or any food.

2. When the patient came to our hospital, she had pains over the joints of her four limbs, sore over her back and shoulders. There was numbness over her four limbs, especially his tiptoe. She had occasional dizziness, palpitation, shortness of breath, tinnitus, forgetfulness and weakness. Her appetite was good. The urination and bowel     movement were normal.

3. T: 36.5°C     R: 18 times/minute    P: 62 times/minute     BP: 110/70mmHg

4. The patient grew normally. She was alert and cooperative. She had chronic sick facial complexion. There was      no sign of yellow sclera or yellowish skin and also no enlargement on the superficial lymph node of her whole body.  Facial features were normal with masses. Her neck was soft without resistance, yet it is not flexible to turn on her neck.  There were slight pressing pains over her shoulders and back. The function of lifting her arms slightly limited. Here trachea was symmetrical. There was no enlargement over her thyroid. Sound of breathing in the lungs was  clear,   without any rhonchi. Rhythm of her heart was 62 times per minute. Heart rate was regular with no murmurs. Her abdomen was soft with no pressing pains and rebound tenderness. There ws no sign of deformity over her spin. There was no obvious edema. There were no pathological reflcetions, but the physiologival reflections existed. The tongue body was light red with white and thin coating. The pulse was deep, string, wiry and unsmooth. 

Diagnostic Differentiation:

TCM: Impediment

Western Medicine diagnosis:

1. rheumatoid arthritis

2. Meniere’s syndrome

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade  care, Common diet, monitoring the blood pressure, once a day.

3. Completed the related examination, three routine inspection, the function of the kidneys and the liver, blood fat, blood sugar, anti-O, RF and IMX..

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

5. Acupuncture and massage: once a day.

6. Avoid wind-cold, regular daily life, have a good mood and take care of diet.

 

Date: April. 13, 2015                                          Time: 10:00 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient complained that she had suffered from repeated pains, accompanied with numbness for 6 years, being severe for 3 months. And she often felt dizziness, weakness, chest oppression, palpitation and shortness of breath. Her sleeping was not good, dreaminess. Her appetite was      not stable. For the pains of joints, sometimes it was better, sometimes it was worse. In recent days, the tip of toes    had stabbing pains. There were the following symptoms, such as tinnitus, forgetfulness, and aching in her lumbar      and knees. Body checked, it was difficult to make a fist because of powerless. There were pressing pains over        her knee-joints and metacarpophalangeal joints. The tongue body was slight red with white and thin coating. The   pulse was string, wiry and unsmooth.

 

Date: April 16,2015                                            Time: 9:00 a.m.

The patient said the pains over her four limbs relieved, and the numbness was better. And the symptoms such as dizziness, palpitation and shortness of breath all improved. Her appetite and sleeping were good. The urination and bowel movement were normal. Body checked, the tongue coating was white and thin, the pulse was deep, string     and unsmooth.

 

Date: April 19, 2015                                          Time: 11:30 a.m.

The patient said The pains improved greatly, and the numbness obviously relieved. The dizziness almost disappeared.

 

Date: April 23, 2015                                          Time: 10:00 a.m.

The patient said the pains over her four limbs and numbness disappeared completely. She could move her joints flexibly. There were no dizziness, palpitation and shortness of breath. She was in a good spirit status. Her appetite   and sleeping were good. The urination and bowel movement were normal. The tongue coating was white and thin, the pulse was deep, wiry and powerful. The patient decided to leave the hospital today. In order to consolidate the effect, the patient took the herbal tea back.

Doctor’s advice after leaving hospital: 

1. Avoid cold-wind. Keep good mood. Pay attention to diet. 

2. Take enough rest to avoid exhausting.