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Brief Summary: On Dec. 17, 2008, Marlon, from Trinidad & Tobago, who has suffered from gout and the joint pains of the lower limbs for 3 years, was hospitalized in our hospital. After about 16 days TCM treatment here, the pains all over his body have disappeared. He was very satisfied with the result.

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Record of Hospitalization

Name: Marlon                                                                                                  Birthplace: USA

Sex: Male                                                                                                          Profession: Secretary

Age: 39                                                                                                              Marital Status: Married

Nationality: Judah                                                                                             Onset Season: Heavy snow after 5 days

Date of Admission: Dec. 17, 2008                                                                    Date of Record: Dec. 18, 2008

Complainer: The patient himself

 

First Medical Record

Date: Dec. 17, 2008                                      Time: 21: 00 p. m.

Marlon, a 39-year-old male, has suffered from the joint pains of the lower limbs for 3 years. He was hospitalized in our hospital for further treatment at 14: 00 p. m. on Dec. 17, 2008.

Essentials for Diagnosis:

1. The patient has suffered from the joint pains of the lower limbs for 3 years.

2. Three years ago, the patient began to feel the joint pains of the lower limbs including knee joint, ankle joint and digital joint. There were symptoms of inflammation and burning sense. It occurred 1-2 times within a week. The frequently repeated occurrence had nothing to do with the changes of climate. The patient felt it became worse after tiredness. He was diagnosed with gout in local hospital and had been given the treatment to reduce his uric acid and relieve pains, but there was no obvious improvement. So he came to our hospital for further treatment. His present symptoms were as follows: pains in the inside part of his left thumb; no inflammation; no binds; acid reflux after getting up in the morning; night urination for 3-4 times; normal bowel movement; good appetite and spirit.

3. The patient was allergic to crab and lobster.

4. T 36.1¡æ, P 58 beats/minute, R 20 times/minute, BP 120/84 mmHg.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. His abdomen was flat and soft. There were no pressing pains and rebound tenderness. Besides, there were no tapping pains in the area of the liver and kidneys. No deformity of the spine and four limbs.

6. He grew normally. He seemed to be of well-built. His expression was natural. His mind was clear. He was cooperative with his mind.

Diagnostic Basis:

TCM: The patient mainly felt the joint pains of his lower limbs, which had nothing to do with the changes of climate. Sometimes, it was accompanied by the symptoms of inflammation and the burning sense. So it was not difficult to be diagnosed with gout. The afflicted skin was inflamed and painful. There was burning sense when it was touched. He also had the symptom of acid reflux. His pulse was deep and slow. His tongue was red with stasis macule. His tongue coating was thin and yellow. So he was diagnosed with gout with the type of damp-heat brewing, static blood obstructing the channels.

Western Medicine:

1. The inflammation and burning pains in the joints of the lower limbs as well as the onset of single joint had no obvious relationship with the changes of climate.

2. The patient was diagnosed with gout in local hospital.

Diagnostic Differentiation:

TCM (Traditional Chinese Medicine): The patient¡¯s gout should be differentiated from rheumatoid arthritis which usually results in the joints swelling in symmetric prismatic. It is very different from hemi-asymmetrical gout. Rheumatoid arthritis can be definitely diagnosed by X-ray and rheumathoid factors examination.  

Western Medicine: The patient¡¯s gout should be differentiated from osteoarthritis which is mainly characterized by hyperosteogeny and the swelling of the joints. Besides, the affected joints will have dull pains. It will become worse after much exercises and the pains will be relieved after rest. The disease mainly occurs in middle and old aged female and it can be diagnosed definitely by X-ray examination.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Gout

Symptoms identification: Damp-heat brewing and static blood obstructing the channels.

Western Medicine diagnosis: Gout

Plans for treatment strategy:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Diet low in purine.

4. Herbal tea.

5. Acupuncture and massage.

 

Date: Dec. 18, 2008                                       Date: 9: 00 a. m.

The patient has suffered from the joint pains of the lower limbs for 3 years. Three years ago, the patient began to feel the joint pains of the lower limbs including knee joint, ankle joint and digital joint. There were symptoms of inflammation and burning sense. It occurred 1-2 times within a week. The frequently repeated occurrence had nothing to do with the changes of climate. The patient felt it became worse after tiredness. He was diagnosed with gout in local hospital and had been given the treatment to reduce his uric acid and relieve pains. He had red tongue, thin and yellow tongue coating. His pulse was deep and fine. Professor Yang thought that his gout was mainly due to damp-heat brewing and static blood obstructing the channels from the theory of TCM. Accordingly the treatment strategy was to clear heat, disinhibit dampness, quicken the blood and free the network vessels. The prescription was as follows: honghua (carthamus flower), huangqi (astragalus root), danggui (tangkuei), danshen (salvia root), etc. 3 dosages in total.

 

Date: Dec. 19, 2008                                       Time: 9: 00 a. m.

The patient didn¡¯t complain about the pains of the lower limbs. But he felt slightly tired. The others were good. The feedback of today¡¯s examinations was as follows: ECG, the function of the liver and kidneys, Blood R, Urine R all were normal. Blood uric acid was 657umol/L.

 

Date: Dec. 20, 2008                                       Time: 9: 00 a. m.

Yesterday the patient walked outside for 2 hours, so he felt the joint pains of his left big toe and left ankle. But there were no symptoms of inflammation and burning sense. There was good improvement after he was given to the medicine to relieve pains. The others were normal. Continue to take the former prescription. 4 dosages in total.

 

Date: Dec. 24, 2008                                       Time: 9:00 a. m.

The patient said he felt pains in his left groin. There were obvious pressing pains which had an influence on his walking. So the doctor added some ingredients into the previous herbal tea such as chuanlianzi (toosendan fruit), wuyao (lindera root ) and etc.

 

Date: Dec. 28, 2008                                      Time: 10: 00 a. m.

His diet and spirit both were good. He consciously felt the fat on his abdomen had lessened. There were still slight pains on his left abdomen. His pulse was deep and thready. The prescription was changed as follows: danpi (moutan root bark), duhuo (duhuo angelica root), mugua (chaenomeles fruit), and etc. 3 dosages in total.

 

Date: Dec. 31, 2008                                       Time: 9: 00 a. m.

The patient said his diet, sleep and spirit were good. He didn¡¯t complain about the pains. So the prescription was the same. 2 dosages in total.

 

Date: Jan. 1, 2009                                         Time: 9: 00 a. m.

The patient decided to leave the hospital tomorrow with 60 days herbal granules for further treatment. The prescription was as follows: huangqi (astragalus root), jixueteng (millettia root and stem), niuxi (achyranthes root) and etc.

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