April 27, 2015, Mr. Pan Rensheng, came from Zhongfang County, who had been
suffering from gouty arthritis for more than 5 years and being severe for 7
days. He was hospitalized in our hospital. He achieved some improvement after 18
days TCM treatment with the help of herbal tea, acupuncture and massage in our
Marital Status: Married
Date of Admission: Apr. 27, 2015
Apr. 27, 2015
Time: 14:00 p.m.
61-year-old man had been suffering from pains over his body for more than 5
years, being severe for 7 days. He was hospitalized in our hospital as a patient
with gouty arthritis for TCM treatment at 14:00 p.m. on Apr. 27, 2015.
patient said he had the pains of the joints of his whole body after overwork 5
years ago. He felt distent pains of his joints, weakness, heavy and tired. He
bought the medicine from the pharmacy by himself, the condition got better.
Recent years, the pains repeatedly attacked. After the physical work, the pains
got worse. After taking the rest, the pains relieved. When the pains appeared,
he felt weak, sore, and the movement of joints limited, especially his upper
joints. There was no allergy history of any food or any medicine.
Mr. Pan came to our hospital, the pains attacked again 7 days ago. The pains ran
over his body, especially his shoulder joints, and the joints movement was
limited. After overwork, the pains got worse. When the weather was cold or in
winter, the pains became severe. He felt tired. He felt sore and distent over
his four limbs. His appetite was good. When he took the cold and spicy food, he
had the symptoms of stomachache, abdominal distension and diarrhea. His
urination was normal.
36.2°C R: 20 times/minute P: 74 times/minute BP: 90/60 mmHg
The patient grew
normally. He was alert and cooperative. He had chronic sick facial complexion.
There was no sign of yellow sclera or yellowish skin. There was no
enlargement on the superficial lymph node of his whole body. Facial
features were normal with masses. There were pressing pains over the top of his
head and tempora bome. The pupillary reaction to light was sensitive. His neck
was soft without resistance. His trachea was symmetrical. There was no
enargement over his thyroid. The jugular vein was of no engorgement. His chest
was symmetrical without deformity. Sound of breathing in the lungs was clear,
without any rhonchi. Rhythm of his heart was 74 times per minute. Heart rate was
regular with no murmurs. His abdomen was soft with no pressing pains and rebound
tenderness. There ws no sign of deformity over his spine. There were pressing
pains over his should joints and around his spine. The meningeal irritation sign
was negative. There were no pathological reflcetions, but the physiologival
reflections existed. The tongue body was dark red with white and thin coating.
The pulse was deep, string and slippery.
2. Chronic Superficial
3. Chronic Proctitis
Treatment strategy and
1. Routine care of
traditional Chinese internal medicine.
2. Grade Ⅱ care,
wind-cold, regular daily life, have a good mood and take care of diet.
4. Completed the related
routine inspection, the function of the kidneys and the liver, blood fat, blood
sugar, anti-O, RF and IMX..
5. Herbal tea: one
dosage a day and drink twice
6. Acupuncture and
massage: once a day
Date: Apr. 28,
2015 Time: 10:00 a.m.
Ming, doctor-in-charge, paid a visit to the patient. The patient complained that
he had suffered from repeated muscle and joint’s pains over his whole body. He
felt tired, weakness, sore and distension. He often took the medicine from the
pharmacy, sometimes his condition improved and sometimes his condition regress.
When he had overwork, his condition got worse, while his condition relieved
after taking a rest. And the movement of joints limited, especially his upper
limbs. 7 days ago, his joint-pains attacked again, and being severe. The pains
runs over his whole body, especially his shoulder joints. He often felt
abdominal distention. It affected his sleeping. The urination and bowel movement
were normal. There were pressing pains over his shoulders and back. The movement
of lifting his arms was normal. The tongue body was light red with white and
thin coating. The pulse was string, slippery and slow.
01, 2015 Time: 9:00 a.m.
patient said the pains over his shoulders and back slightly relieved. Yet he
still had the stomach distension. His appetite was poor. He could lift his arms
normally. There were pressing pains over his shoulders and back. The tongue was
light white with white and thin coating. The pulse was string.
05, 2015 Time: 9:00 a.m.
signs of the patient were stable. The patient said the back pains obviously
improved. And he could turn his neck flexibly. And the stomach distension
relieved. His appetite was better than before. His sleeping was normal. The
urination and bowel movement were normal. While he still had the pressing pains
over his shoulders.
09, 2015 Time: 9:00 a.m.
patient said his condition was stable, not changeable. Kept to take the previous
Date: May 15, 2015 Time: 9:00 a.m.
patient said the lumbago almost disappeared. And the pressing pains over his
shoulders and back relieved obviously. He decided to leave the hospital.
Took the herbal tea back for continuing treatment.