Name: Basima                                                                                                      Sex: Female

Age: 52                                                                                                                Marital Status: Married

Nationality: Dubai                                                                                                Date of Admission: Sep. 14, 2012

Companion: Alone

First Medical Record

Date: Sep. 15, 2012                               Time: 9:00 a.m.

This 52-year-old lady had been suffering from skin impediment, accompanied by skin over her upper limbs and hands being darker and thicker for 3 years and fingers being tight for 1 year. The patient was hospitalized in our hospital for TCM treatment at 8 p.m. on September 14, 2012.

Essential for Diagnosis:

1. The patient h ad been suffering from skin impediment, accompanied by skin over her upper limbs and hands being darker and thicker for 3 years and fingers being tight for 1 year.

2. Five years ago, the patient suffered tight feeling over her whole body skin and stiff limbs occasionally, which lasted for one or two hours. Gradually, she felt discomfort over her whole body all day long. Three years ago, her hands and upper limbs became darker and thicker obviously. One year ago, the symptom of stiff hands appeared, and three weeks ago, she suffered from finger ulcers. Before coming to our hospital, she had taken herbal medicines delivered from our hospital.

3. When the patient came to our hospital, the color of the skin over her upper limbs and hands was dark. The skin became thicker and the pores became smaller. Wrinkles over the skin disappeared or became lighter. Fingers of both hands were stiff, with numb finger tips. Four limbs also were stiff. Joints of her upper limbs were painful. She had heavy feeling of her body. Knee joints also were painful. She had difficulty in walking, with poor balance. When the weather changed, her conditions became severe, but the color did not show any changes. One month ago, when decorated for her house, she suffered from cough. And now, when coughed, she suffered obvious pains over her right rib areas, with yellowish or whitish phlegm. In the recent two years, she had dry vomiting and hiccups occasionally. Her appetite was good. Bowel movement and urination were normal. Sleep was good.

4. T: 36.3＜C   R: 20 times/minute    P: 80 times/minute   BP: 110/76mmHg

5. The patient was alert and cooperative and had a positive body position. She grew normally with slightly stiff facial complexion. Skin over her face and lower jaw were stiffer. Skin over her neck, upper back, front arms and hands were thicker and stiffer. The above conditions showed pigmentation. Fingers of both hands were stiff, with tight skin. The second joint of the third finger of her right hand was of ulcer. Skin pigmentation of her forehead lost, with the size of 6*3 cm white spots showed. Breath sounds of her livers were too coarse, with no dry and wet rales. Her heart rhythm was 78 times/minute. Heart rate was regular, with no murmurs. Her tongue was slightly red, with small cracks and teeth marks over the edge of the tongue. Her coating was yellowish. Her pulse was wiry, thready and slightly weak.

First Diagnosis:

TCM: Skin impediment.

Symptom identification: Coldness and dampness obstructing the channels, yang deficiency of the spleen and kidneys.

Western medicine diagnosis: Systemic scleroderma.

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Å care.

3. Common diet.

4. Pathogenesis: Cold and damp pathogen obstructing channels, and yang deficiency of the spleen and kidneys 

5. TCM strategy: Removing coldness and dampness, free the channels, warming and tonifying the spleen and kidneys.

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

7. Acupuncture and massage: once a day

8. Steaming and washing the skin

9. Have more medical examination if necessary.

Date: Sep. 16, 2012                                             Time: 9:30 a.m.

Doctor Zhu Ming paid a visit to the patient. The patient complained that skin over upper limbs and hands being darken and thicken for 3 years, accompanied by stiff fingers for one year. Right now, color of the skin over her upper limbs and hands was deep dark. Pores over the skin became smaller. Wrinkles over the skin were disappeared or became lighter. Fingers of both hands were stiff. Tips of her fingers were numb. Skin over her hands was tight. When the weather was turning cold, her conditions became severe. Her tongue was slightly red with thin and yellowish coating. He pulse was wiry, thready and slightly weak.

From the view of TCM, Zhu Ming, the doctor thought that the case of the patient could be diagnosed as skin impediment, due to cold and damp pathogen obstructing channels, and yang deficiency of the spleen and kidneys 

Date: Sep. 18, 2012                                             Time: 9:30 a.m.

Cough of the patient was less. Skin color over her left hand became lighter. No obvious sweating. Till now, no obvious change on the ulcers over her fingers. Her tongue was slightly red with thin and yellowish coating. He pulse was wiry, thready and slightly weak.

Date: Sep. 20, 2012                                             Time: 9:30 a.m.

The patient complained that her throat was quite dry, but not liked to drink water.

Date: Sep. 24, 2012                                             Time: 9:30 a.m.

The patient still felt dryness in her mouth. Her right back and right rib part were painful. Her right wrist and left side of her left foot were also painful. Sleep was not so good. Conditions of her tongue and pulse were as before.

Date: Sep. 27, 2012                                             Time: 9:30 a.m.

Skin over the back of the patient¨s hands became softer. Color of the front part of her arms became lighter. Her tongue was red with yellowish coating.

Date: Oct. 4, 2012                                               Time: 9:30 a.m.

The patient said skin over her hands and face all became somewhat softer. Color of the index and ring fingers of her right hand became softer obviously. Joints of her whole body were painful occasionally, because she stopped taking the pain-killers. However, the symptom of pain was better than before. She had itchy throat and cough. She did not have bowel movement for three days. Her tongue was red with yellowish and slightly thick coatings. Her pulse was wiry and thready.

Date: Oct. 7, 2012                                               Time: 9:30 a.m.

The patient said she had bowel movement on 5, October. And in recent days, she did not suffer any problem in bowel movement.

Date: Oct. 10, 2012                                              Time: 9:30 a.m.

The patient felt comfortable with her whole body skin. Her facial skin was softer. Corrugation of her upper lip was reduced a lot. White spot over her forehead shrank. Skin over the front part of her upper limbs was softening obviously. The patient said skin over her fingers was very tight like wood, but now, they were softer. Finger ulcers now only showed on her small fingers, but much better. Skin over the back of her fingers closing to her nail were turning white gradually, approaching normal skin colors. Pains over her right rib due to cough for a long time were better. Pricking pains were showed over her left foot bottom, and her walks were affected a lot. After recent three days treatment, it turned better. Her appetite was good. Bowel movement and urination were normal. Sleep was good. Her tongue was slightly red, with slightly yellowish and thick coating. Her pulse was wiry and thready.

Date: Oct. 13, 2012                                              Time: 9:30 a.m.

Conditions of the patient were stable. Her tongue was slightly red. Her pulse was thready and wiry.

Date: Oct. 16, 2012                                              Time: 10:30 a.m.

The patient¨s conditions were gradually turning better. She felt warmness over her whole body, with little bit sweat during the night of 14, October.

Date: Oct. 19, 2012                                              Time: 9:30 a.m.

The patient herself felt slight warmness over her body.

Date: Oct. 22, 2012                                              Time: 9:30 a.m.

The patient said she sweated a lot yesterday, even wetted her paja.m.as. She had coughs during the night, with phlegm in her throat. Her mouth and throat were slightly dry. Small fingers joints over hands were painful. Her tongue was slightly red with yellowish and thick coating. Her pulse was wiry and thready.

Date: Oct. 23, 2012                                              Time: 9:30 a.m.

The patient still sweated a lot.

Date: Oct. 25, 2012                                              Time: 9:30 a.m.

The patient¨s sweating symptom was better. Skin loose was gradually obvious. Small finger joints of both hands were still painful.

Date: Oct. 28, 2012                                              Time: 9:30 a.m.

The patient said her joint pains improved.

Date: Nov. 1, 2012                                               Time: 9:30 a.m.

The patient said joint pains were reduced. Her skin was softer obviously. Skin pigmentation was improved evidently. Only mild sweat showed. However, power of her fingers declined. Her tongue was slightly red with slightly yellowish coating. Her pulse was wiry and thready.

Date: Nov. 11, 2012                                               Time: 9:30 a.m.

Joints of the patient were still mild hot. Red and swollen symptom was improved, but pains were still obvious.

Date: Nov. 13, 2012                                               Time: 9:30 a.m.

The patient complained dryness in her mouth, and dry stool. She also felt dry and tight over her skin.

Date: Nov. 15, 2012                                               Time: 9:30 a.m.

Temperature of the patient¨s skin was normal. Pains over her body were reduced a lot.

Date: Nov. 20, 2012                                               Time: 10:00 a.m.

The patient recently felt that her limbs were more flexible than before. Pains were gone. Muscles over her fingers were softer. Yellowish color of her tongue was reduced somewhat. Dryness in her mouth was not that obvious as before.

Date: Nov. 25, 2012                                               Time: 10:00 a.m.

The patient¨s condition was in a good state. Temperature of her skin was normal, not too cold nor too hot. Her tongue coating was a little yellowish, but moist. Her stool was a little dry.

Date: Dec. 1, 2012                                                Time: 9:30 a.m.

Temperature of her skin was normal, not too cold nor too hot. Her bowel movement was also normal now.

Date: Dec. 5, 2012                                                Time: 9:30 a.m.

In the recent two days, the patient¨s skin temperature was a little low. Her skin was much more softer than before she came to our hospital.

Date: Dec. 10, 2012                                                Time: 9:30 a.m.

Pains over her finger joints were almost reduced. She caught cold yesterday night, and now she suffered running nose and slight sore throat. Her tongue was slightly red, with slightly yellowish coating. Her pulse was slightly floating.

Date: Dec. 13, 2012                                                Time: 9:30 a.m.

For the expiration of visa, Ms. Basima asked to leave our hospital today. Till today, tight and swelling sensation over the skin of her face, four limbs and back were reduced obviously; when touching, much softer than before. Before came to our hospital, her skin temperature was abnormal, too cold. Right now, her skin temperature was close to normality. The color of the sick skin was also closing normal. Pains over her joints were reduced a lot. Her walking ability was improved a lot, with less pain during walks. Skin wrinkles showed out. Her tongue was slightly red, with slightly yellowish coating. Her pulse was slightly floating.

Doctor¨s advice after leaving hospital:

1. Avoid wind-cold, maintain good moods.

2. Take care of the diet, with no spicy, hard and acid food.