TCM China:

Record of Herbal Treatment Of Pan Chunmei, from China Improvement Of Rheumatoid Arthritis

 

 

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Brief Summary: On March 23, 2016, Ms. Pan Chunmin, from Zhongfang County, who had been suffering from stuffy pain and flatulence over her epigastrium for 20 years, accompanied with vomiting and hiccough, being severe for half a month. She was hospitalized in our hospital. Her 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: Ms. Pan Chunmei                                             Sex: Female

Age: 45                                                                       Marital Status: Married

Nationality: China                                                       Date of Admission: March 23, 2016

Companion: Alone

                            First Medical Record

Date: March 23, 2016                                    Time: 12:00 a.m.

This 45-year-old woman had been suffering from abdominal distension and pain, accompanied with vomitting and hiccough, being severe for half a month. The patient was hospitalized in our hospital as a patient with chronic superficial gastritis for TCM treatment at 12:00 a.m. on March 23, 2016.

Essential for Diagnosis:

1. The patient said 20 years ago she had abdominal distension and pain, accompanied with vomitting and hiccough. Her bowel movement was abnormal. The function of digestion was not bood, it could not digest the food. She felt stomach distending, even she ate less. Sometimes she had bitter mouth, constipation and flatus. She took the treatment for many years, there was no improvement. On March 8th, 2016 the patient went to take a stomachoscopy, the result reported that the patient sufferred with chronic superficial gastritis. In order to relife the pain, the patient came to our hospital for TCM treatment. The patient have the following medical history, cervical spondylosis, frozen shoulder and gonitis. She always had joint pain and it is difficult to move. The activity was limited. 

2. When the patient came to our hospital, her spirit status was not good. She had distending pains over her epigastrium. She felt bitter in her mouth, stuffy pain and distending over her abdomen, accompanied with vomitting and hiccough. To defecate four times a day, the food was not digested. Her urination was normal. There was obvious pain over her shoulder joints, lower back and knee-joints. And she had headache as well. She was afraid of cold, yet sweating over her soles and palms. It was difficult to move, her sleeping was not good.

3. T: 36.5°C     R: 20 times/minute    P: 80 times/minute     BP: 130/90mmHg

4. The patient grew normally. She was alert and cooperative. She had chronic sick facial complexion. She moved slowly. 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 without masses and pressing pains. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. Her ears were normal without secreta and pressing pain. Her hearing was normal. Her neck was soft without resistance. While she was hard to turn her neck, when she turn her neck, it made the pain over her right shoulder. There was no enlargement over her thyroid.The jugular vein was of no engorgement. Her windpipe appearance was good and in the center. Her chest was 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 with no pressing pains and rebound tenderness. There was no sign of deformity over her spine. There was obvious pressing pains close to her third or fouth lumbar vertebra. And there was obvious pain over her knee-joints. The meningeal irritation sign was negative. There were no pathological reflections, but the physiological reflections existed. The tongue body was light red with white and thin coating. The pulse was deep and string.

Diagnostic Differentiation:

TCM: Impediment and stomachache.

Western Medicine diagnosis:

1. rheumatoid arthritis

2. chronic superficial gastritis

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade  care, slight diet, avoid spicy food.

3. Completed the related examination, three routine inspection, the function of the kidneys and the liver, HB 5 test, 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: March 23, 2016                                          Time: 12:00 a.m.

Dr. Luo, doctor-in-charge, paid a visit to the patient. The patient complained that 20 years ago she had abdominal distension and pain, accompanied with vomitting and hiccough. Her bowel movement was abnormal. The function of digestion was not bood, it could not digest the food. She felt stomach distending, even she ate less. Sometimes she had bitter mouth, constipation and flatus. She took the treatment for many years, there was no improvement. On March 8th, 2016 the patient went to take a stomachoscopy, the result reported that the patient sufferred with chronic superficial gastritis. In order to relife the pain, the patient came to our hospital for TCM treatment. The patient have the following medical history, cervical spondylosis, frozen shoulder and gonitis. She always had joint pain and it is difficult to move. The activity was limited. To defecate four times a day, the food was not digested. Her urination was normal. There was obvious pain over her shoulder joints, lower back and knee-joints. And she had headache as well. She was afraid of cold, yet sweating over her soles and palms. Her sleeping was not good. The tongue body was light red with white and thin coating. The pulse was deep and string.

Date: March 24, 2016                                          Time: 10:00 a.m.

The patient said there was no obvious improvement. Taking the herbal tea to observe the effect.

Date: March 25, 2016                                          Time: 9:00 a.m.

The patient said the discomfort, bitter mouth and distending pain improved. And the flatulence in the lower abdomen also relieved.

Date: March 26, 2016                                          Time: 9:00 a.m.

The patient was in a good spirit status. She said the flatulence in her abdomen obviously relieved. And the vomitting and hiccough both improved.

Date: March 30, 2016                                          Time: 9:00 a.m.

The patient said the vomitting and hiccough disappeared, and the food could be digested completely. Her bowel movement was better.

Date: April 03, 2016                                          Time: 9:00 a.m.

The patient said the distending pain and flatulence in her abdomen almost disappeared. The vomitting and hiccough disappeared completely. The pain over her shoulder joints, her lower back and knee-joints reduced obviously, the same as her headache. And the activity improved.

Date: April 05, 2016                                          Time: 9:00 a.m.

The patient said the condition was stable. The symptoms almost disappeared and her condition was better day by day. The pain over her shoulder joints, her lower back and knee-joints also disappeared. Her sleeping was normal.

Date: April 08, 2016                                          Time: 9:00 a.m.

The patient decided to leave the hospital today. She had recovered.