Brief Summary: On Apr. 15, 2009, Desmond, who has suffered from rheumatoid arthritis, accompanied with the symptoms of the joint pains all over the body for 8 months and headache for 3 months, was hospitalized in our hospital. He has achieved obvious improvement after 10 days TCM treatment here.

Name: Desmond                                                                                                         Profession: Businessman

Sex: Male                                                                                                                    Age: 42

Nationality: Sri Lanka                                                                                                 Marital Status: Married

Date of Admission: Apr. 15, 2009                                                                              Onset Season: Vernal equinox

Date of Record: Apr. 15, 2009                                                                                   Complainer: The patient himself

First Medical Record

Date: Apr. 15, 2009                                      Time: 23: 00 p. m.

Desmond, a 42-year-old male, has suffered from rheumatoid arthritis, accompanied with the symptoms of the joint pains all over the body for 8 months and headache for 3 months. He was hospitalized in our hospital for treatment at 23: 00 p. m. on Apr. 15, 2009.

Essentials for Diagnosis:

1. The patient has suffered from rheumatoid arthritis, accompanied with the symptoms of the joint pains all over the body for 8 months and headache for 3 months.

2. Eight months ago, the patient felt joint pains all over the body without obvious reasons. At that moment, he didn¡¯t pay much attention to it. Four months ago, he felt headache, so he came to our hospital at 23: 00 p. m. on Apr. 15, 2009.

3. T 36.3¡æ, R 20 times/minute, P 80 times/minute, BP 110/80mmHg.

4. He grew normally with common nutrition. His mind was clear. He had an expression of chronic illness and tiredness. His body was in a positive posture and he was cooperative with clear mind.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The patient felt joint pains all over the body and headache.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient has suffered from rheumatoid arthritis, accompanied with the symptoms of the joint pains all over the body for 8 months and headache for 3 months. Wind-cold-damp evil rested on the channels and network vessels and obstructed qi and blood, which resulted in joint pains. Due to the obstruction of the channels and network vessels, the essence as well as the blood could not reach the brain, then the patient felt headache. From the aspect of TCM, it was impediment pattern.

Western Medicine: The patient has suffered from rheumatoid arthritis, accompanied with the symptoms of the joint pains all over the body for 8 months and headache for 3 months.

Diagnostic Differentiation:

TCM: The patient¡¯s headache should be differentiated from unendurable headache, which is accompanied with the symptoms of sudden onset, intense, continuous and paroxysmal headache and vomiting like spurting. The patient will die if he hasn¡¯t taken the proper treatment in time. So they are not difficult to be distinguished.

Western Medicine: The patient¡¯s headache should be differentiated from nerve headache. Regarding nerve headache, the onset of the part is not fixed, usually accompanied with the symptoms of tightening sense, heavy sense, numb pains, distending pains and stabbing pains, which are closely connected with mood swings, tiredness, insomnia, etc. So they are not difficult to be distinguished.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Impediment pattern

Symptom identification: Depletion of liver-kidney, obstruction of channels and network vessels due to damp-heat.

Western Medicine: Rheumatoid arthritis

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Common diet.

4. TCM treatment strategy: supplement the liver and kidneys, clear heat, dispel dampness, quicken the blood circulation and free the channels and network vessels.

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

6. Acupuncture and massage: once a day.

7. Have more medical examination if necessary.

Date: Apr. 16, 2009                                      Time: 10: 00 a. m.

The patient has suffered from joint pains all over the body for 8 months and headache for 3 months. Eight months ago, the patient felt joint pains all over the body without obvious reasons. Four months ago, there was the symptom of headache. At that moment, he didn¡¯t pay much attention to it and had not taken any examination and treatment. At present, he felt the joint pains all over the body. There was scorching hot of the heels after he walked for a certain period, but there was no deformity of the joints. He felt headache, sometimes it could result in the pains of the eyes. He was easy to get angry. The headache became severe after irritation. He had constipation. There was discomfort of the shoulders and back. Sometimes, he had nosebleed. His sight was good. There were no the symptoms of deafness and tinnitus. His sleep was good. He had dry and bitter mouth. His mother had the history of rheumatoid arthritis, and he had the kidney stones in the past. His tongue was pale red and slightly enlarged. His tongue coating was thin and white. His pulse was thready and weak. Professor Yang believed that the patient was mainly characterized by joint pains all over the body, so he had suffered from impediment pattern due to depletion of liver-kidney, obstruction of channels and network vessels due to damp-heat. Accordingly the treatment strategy was to supplement the liver and kidneys, clear heat, dispel dampness, quicken the blood circulation and free the channels and network vessels. The prescription was as follows: chuangxiong (ligusticum root), danggui (tangkuei), dangshen (codonopsis root), etc. 3 dosages in total.

Date: Apr. 17, 2009                                      Time: 14: 00 p. m.

According to the feedback, there was no abnormity of the examination of B ultrasound. The examinations of his bowel movement, urine, the function of the liver and kidneys were normal.

Date: Apr. 18, 2009                                      Time: 10: 00 a. m.

Compared with before, there was 20% improvement of the pains all over the body. He didn¡¯t feel the headache. The symptoms of dry and bitter mouth were better than before. The urine and bowel movement were normal. The former prescription was changed a little. 4 dosages in total.

Date: Apr. 22, 2009                                      Time: 10: 00 a. m.

The patient said the pains all over the body were further improved. But he had the symptoms of throat pains, running nose and cough due to having a cold in the recent two days. The former prescription was changed a little. 4 dosages in total.

Date: Apr. 25, 2009                                      Time: 10: 00 a. m.

The patient decided to leave the hospital tomorrow with taking 30 days herbal tea to consolidate the effect.

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