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Brief Summary: On Oct. 20, 2009, Fakhreya from Bahrain, who has suffered from lumbar disc protrusion and rheumatoid arthritis, was hospitalized in our hospital. She has achieved much improvement after 83 days TCM treatment here.

 

Record of Hospitalization

Name: Fakhreya                                                                                                   Birthplace: Bahrain

Sex: Female                                                                                                          Profession: Businesswoman

Age: 42                                                                                                                 Date of Admission: Oct. 20, 2009

Nationality: Muslim                                                                                              Date of Record: Oct. 20, 2009

Marital Status: Married                                                                                       Onset Season: Autumn begins

Complainer: The patient herself

 

First Medical Record

Date: Oct 20, 2009                                        Time: 19: 00 p. m.

Fakhreya, a 42-year-old female, who has suffered from lumbar disc protrusion and rheumatoid arthritis, was hospitalized in our hospital at 19: 00 p.m. on Oct. 20, 2009.

Essentials for Diagnosis:

1. The patient had suffered from pains of the waist and numbness of her both lower limbs for 16 years.

2. In October of 1993, the patient began to feel pains of the waist and numbness of her both lower limbs without obvious reason. Her pains had some relationship with the changes of the climate. Besides, she felt that pains gradually became worse when she slept or walked for a little long time. Then she went to a local hospital and she was diagnosed as lumbar disc protrusion by MRI. However, she did not get obvious improvement after the local hospital¡¯s treatment. She could only walk for about 500 miles. Then she had to have a rest. To pursue the comprehensive treatment, she came to our hospital on Oct. 20, 2009.

3. T 35.8¡æ, R 20 times/minute, P 80 times/minute, BP 100/50mmHg.

4. She grew normally with common nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. Her body was in a positive posture and she 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 88 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The patient felt pains on the waist and the numbness of her both lower limbs. Besides, her pains had some relationship with the changes of the climate. She could only walk for about 500 meters. Then she had to have a rest.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient had felt pains of the waist and numbness of her both lower limbs for 16 years. Besides, her pains had some relationship with the changes of the climate. She felt that the pains gradually became worse when she slept or walked for a little long time. She could only walk for about 500 meters. Her history was long. Besides, she had vacuity of qi and blood, insecurity of the defensive exterior. So the pains came to her again and again. At the same time, her sinews deprived of the nourishment, so she felt weakness of the whole body. Her tongue coating was pale yellow. Her pulse was wiry. According to the symptoms of the tongue and pulse, she was diagnosed as impediment pattern.

Western Medicine: The patient had felt pains of the waist and numbness of her both lower limbs for 16 years. Besides, her pains had some relationship with the changes of the climate. She felt that the pains gradually became worse when she slept or walked for a little long time. She could only walk for about 500 meters. She was diagnosed as lumbar disc protrusion by MRI in her local hospital.

Diagnostic Differentiation:

TCM: The patient¡¯s impediment pattern should be differentiated from wilting pattern, which is mainly characterized by limp, weak and emaciated limbs with numbness of the muscles. If the condition becomes serious, the patient can not grasp anything or stand. But usually the patient has no joint pains and these symptoms are mostly limited to the lower limbs. So they are not difficult to be distinguished.

Western Medicine: The patient¡¯s lumbar disc protrusion should be differentiated from pyriformis syndrome. If one suffers from pyriformis syndrome, the patient will feel pains on the buttocks and thighs. The pressure pain point lies in the buttocks and the muscles on the buttocks will be atrophic. The tension test of pyriformis shows ¡°+¡±. So they are not difficult to be distinguished.

First Diagnosis:

TCM diagnosis: Impediment pattern.

Symptom identification: qi stagnation and blood stasis, cold-damp obstructing the sinews.

Western Medicine diagnosis: Lumbar disc protrusion and 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: boost qi and quicken the blood, dispel cold and eliminate dampness.

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

6. Acupuncture and massage: once a day.

7. Have more medical examinations if necessary.

 

Date: October 21, 2009                                       Time: 10: 00 a. m.

The patient had felt pains of the waist and numbness of her both lower limbs for 16 years. Besides, her pains had some relationship with the changes of the climate. She felt that the pains gradually became worse when she slept or walked for a little long time. She could only walk for about 500 meters. Her tongue coating was pale yellow. Her pulse was wiry.

TCM diagnosis: Impediment pattern

Symptom identification: qi stagnation and blood stasis, cold-damp obstructing the sinews.

Western Medicine diagnosis: Lumbar disc protrusion and rheumatoid arthritis.

TCM treatment strategy: boost qi and quicken the blood, dispel cold and eliminate dampness.

Then according to the patient¡¯s latest symptoms, our expert team prescribed a special formula for her for the first time.

 

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

She was given the routine examinations of the blood, urine and bowel movement and the function of the liver and kidneys. Her examination¡¯s feedback had no abnormal result. So she was told to use the same formula.

 

Date: October 29, 2009                                       Time: 10: 00 a. m.

The patient¡¯s pains on the waist had got some improvement. Her felt gastrectasia and gastric acid. Then our experts changed her formula a little for the first time. 

 

Date: November 1, 2009                                       Time: 10: 00 a. m.

The patient¡¯s pains continued to get improvement. Besides, she said that she had no gastrectasia and gastric acid after taking our herbal tea. Her other conditions were normal. At the same time, our experts added some other kinds of herbs to prevent the flu.

 

 Date: November 4, 2009                                       Time: 10: 00 a. m.

The patient said that she felt pains on the waist last night and she was afraid that the menstruation would come. To let her feel more comfortable, our experts prescribed a new formula again.

 

Date: November 7, 2009                                       Time: 10: 00 a. m.

The patient had menstruation from the fifth of this month. Her pains on the waist were OK. Then we changed the formula a little for the third time according to her latest condition.

 

 Date: November 11, 2009                                       Time: 10: 00 a. m.

The menstruation ended today. She still felt the pains on the waist and the joints. Her appetite was normal. Then we changed her formula a little for the fourth time.

 

Date: November 16 2009                                       Time: 10: 00 a. m.

The patient said that her pains became better than before. Then she was told to use the same formula to consolidate the result.

 

Date: November 20 2009                                       Time: 10: 00 a. m.

The patient felt palpitations and dizzy sometimes. Her other conditions continued to become better. Then our expert team prescribed a new formula for her for the third time.

 

Date: November 25 2009                                       Time: 10: 00 a. m.

The above condition had become better. Then she used the same formula.

 

Date: December 5 2009                                        Time: 10: 00 a. m.

It was the second day of the menstruation. She felt pains of the waist. The color of the menstruation was dark red. Then we prescribed a new formula for her again.

 

 Date: December 10 2009                                      Time: 10: 00 a. m.

The patient had slight pains on the waist and the joints. Besides, the pains had relationship with the changes of the climate. According to her condition, we prescribed a new formula for her for the sixth time.

 

Date: December 15 2009                                       Time: 10: 00 a. m.

The patient felt pains sometimes. Besides, the pains had relationship with the changes of the climate. Then we changed the above formula a little.

 

 Date: December 19 2009                                       Time: 10: 00 a. m.

The patient¡¯s condition had got some improvement. Then she used the same formula.

 

Date: December 25 2009                                       Time: 10: 00 a. m.

The patient¡¯s condition was stable. Then she still used the same formula to consolidate the result.

 

Date: January 4 2009                                         Time: 10: 00 a. m.

The patient had menstruation again. Then we prepared a new formula for her.

 

 Date: January 4 2009                                         Time: 10: 00 a. m.

After 83-day treatment of boosting qi, quickening the blood, dispelling cold, eliminating dampness, and adjusting the treatment according to her symptoms, together with acupuncture and massage, the patient had got obvious improvement. The patient decided to leave the hospital tomorrow.

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More Rheumatoid Arthritis cases that we helped well:

Case-1  Case-2  Case-3  Case-4  Case-5

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