Record of Herbal Treatment Of Mr. Zhou Jianping, from China Improvement Of Gouty arthritis

TCM China:

Record of Herbal Treatment Of Mr. Zhou Jianping, from China Improvement Of Gouty arthritis

 

 

 

 

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Brief Summary: On April 27, 2015, Mr. Zhou Jianping, from Zhongfang County near our hospital, who had been suffering from headache and dizziness for more than 8 years, being severe for 5 days. He was hospitalized in our hospital. His condition got great improvement after 16 days TCM treatment with the help of Acupuncture, Herbal tea and Tuina in our hospital.

Record of Hospitalization

Name: Mr. Zhou                                                          Sex: Male

Age: 40                                                                        Marital Status: Married

Nationality: China                                                        Date of Admission: April 27, 2015

Companion: Alone

First Medical Record

Date: March. 26, 2015                                    Time: 11:00 a.m.

This 62-year-old man had been suffering from repeated joint-pains over his lower limbs for more than 4 years, being severe for half month. The patient was hospitalized in our hospital for TCM treatment as a patient with gouty arthritis at 10:00 a.m. on March 26, 2015.

Essential for Diagnosis:

1. The patient had been suffering from repeated joint-pains over his lower limbs for more than 4 years, being severe for half month. He had no allergy history of any medicine or any food.

2. When the patient came to our hospital, he suffered the redness and swelling of knee-joits and foot thumb joints, accompanied with burning pains, especially his knee-joints. He could not stand and walk for a long time. The function of stretching and bending his joints was limited, yet it was not related with the weather changes. Sometimes he had dizziness and tinnitus, decreased hearing and soreness and weakness of his waist. His appetite and sleeping were good. And the urination and bowel movement were normal.

3. T: 36.5°C     R: 20 times/minute    P: 88 times/minute     BP: 150/90mmHg

4. The patient grew normally. He was alert and cooperative. He had chronic sick facial and flushing complexion. He was in compulsive position. There was no sign of yellow sclera or yellowish skin. There was no enlargement on the superficial lymph node of his whole body. His neck was soft without resistant, he could turn his neck flexibly. His windpipe appearance was good and in the center. There was slight distention of jugular vein. There was no enlargement on his thyroid gland. His chest was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 88 times per minute. Heart rate was regular with no murmurs. We did not hear any pathologic sound. His abdomen was soft with no pressing pains, rebound tenderness and enclosed mass. There was no sign of deformity over his spine. There was no obvious pressing pains around his lumbar vertebra. The knee-joints of his lower limbs was obviously red and swell with pressing pains. There was large swelling of his foot thumbs. The function of stretching and bending over his knee-joints was limited. No pathological neuropathic positive. His tongue was dark red with yellow coating. His pulse was deep, rapid and unsmooth.

Diagnostic Differentiation:

TCM: Pains Impediment

Western Medicine diagnosis:  Gouty arthritis

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade  care.

3. Diet of low salt and low fat. Monitoring the blood pressure, once a day.

4. Completed the related examination, three 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

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

 

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

Dr. Ming, doctor-in-charge, paid a visit to the patient this morning. The patient suffered repeated joint-pains over his lower limbs for more than 4 years, being severe for half month. Recently, she suffered the redness and swelling of knee-joits and foot thumb joints, accompanied with burning pains, especially his knee-joints. He could not stand and walk for a long time. The function of stretching and bending his joints was limited, yet it was not related with the weather changes. Sometimes he had dizziness and tinnitus, decreased hearing and soreness and weakness of his waist. His appetite and sleeping were good. And the urination and bowel movement were normal. He was in compulsive position. The knee-joints of his lower limbs was obviously red and swell with pressing pains. There was large swelling of his foot thumbs. The function of stretching and bending over his knee-joints was limited. According to the above condition, Dr. Made the treatment strategy.

 

Date: March 30, 2015                                            Time: 9:00 a.m.

The patient said he felt the pains of his knee-joints relieved. He could walk for about 100 meters. His appetite and sleeping were better. The dizziness was better, while the tinnitus was the same. And he still feel weakness and soreness of his waist. His urination and bowel movement were normal. There was obvious pressing pains over his foot thumbs and knee-joints.

 

Date: April 1, 2015                                            Time: 9:00 a.m.

Test reports:

Urine routine shows normal. The report of the blood routine, oxyphil cells 0.52; neuter cell rate 70.40; lymphocyte rate 16.1%; oxyphil cells rate 5.40;  hemoglobin 173G/L; HCT 0.265; MCV 102.50, etc. According to the reports, doctor adjusted his formula.

Date: April 5, 2013                                            Time: 9:00 a.m.

The vital signs of the patient were stable. And his spirit status was obviously better. And the redness and swelling of his knee-joints and foot thumbs relieved greatly, he could walk for 1 to 2kilimeters.  And his appetite was better. The sleeping was normal. Yet he still feel weakness and soreness over his waist. The color of urine was yellow. The pressing pains improved obviously over his knee-joints. And the function of stretching and bending was already normal. The tongue body was dark red with thin and yellow coating. The pulse was string and slippery.

 

Date: April 9, 2013                                            Time: 9:00 a.m.

The patient said the joint-pains of his four limbs almost disappeared. He could walk flexibly and normally. His appetite and sleeping were normal, as same as his urination and bowel movement.

 

Date: April 13, 2013                                            Time: 9:00 a.m.

The vital signs of the patient were stable. The patient said the joint- pains disappeared completely. He could move his joints normally. The tinnitus was also improved. And his vision was better than before. There was no obvious pressing pains over his knee-joints. The tongue coating was thin and yellow. The pulse was string and slow. The patient decided to leave the hospital today.