2010, Rodaba, from Bahrain, who had been suffering from pains over his bone joints for 5 years
On December 10, 2010, Rodaba, from Bahrain, who had been suffering from pains over his bone joints for 5 years, developed into severe pains below her lumbar portion for 1 year, was hospitalized in our hospital. She achieved some great improvement after nearly two months’ TCM treatment.
Record of Hospitalization Name: Rodaba Sex: Female Age: 64 Marital Status: Married Nationality: Muslim Date of Admission: Dec. 10, 2010 Companion: Her son First Medical Record Date: Dec. 10, 2010 Time: 10:00 am This 64-year-old lady had been suffering from pains over his bone joints for 5 years, developed into severe pains below her lumbar portion for 1 year. The patient was hospitalized in our hospital for TCM treatment at 7:40 am on December 10, 2010. Essential for Diagnosis: 1. The patient had been suffering pains over his bone joints for 5 years, developed into severe pains below her lumbar portion for 1 year. 2. Five years ago, the patient suffered joint pains over her whole general body without any evident cause. At that time, the patient did not pay too much attention to it, and the pains were not very severe, therefore, she did not take any examinations and treatment. In the recent one year, pains became severe, the lumbar portion and her two lower limbs in particular. She went to the local hospital for the MRI examinations on her neck and lumbar. The report presented that she suffered from senile joint degenerative disease. The doctor gave her some medicines for calcium supplement and pain-killers, but the therapeutic effects were not good. 3. When the patient came to our hospital, she felt pains over her whole body joints and bones, particularly pains over her lower limbs and pressing-pains over her lumbar muscles. She felt very fatigued when walking, with pains over her feet vola. The pains became much severe after exercises. She had dry throat. She was easy to be fatigued. She also had stomachaches. Appetite was good. Sleep was just ok. Her spiritual activity was not good. She, at the same time suffered constipation. Urination was ok. Her tongue was slightly red with yellowish tongue coating. There was Thorn of cricoid cartilage and base of tongue. Her pulse was weak and wiry. 4. T: 36.2°C R: 20 times/minute P: 58 times/minute BP: 124/80mmHg 5. The patient grew normally. She was a little bit fat. Her spiritual activity was not good. She had chronic disease complexion with painful facial expressions. She had normal gait, but there were pains over her feet volas and knees when walking. 6. The size and formation of her thorax were normal. No enlargement with her heart. Rhythm of her heart was 56 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. Diagnostic Basis: TCM: The patient had suffered from pains over her bones and joints of her whole general body, developed into severe pains below her lumbar portion. Her lower limbs were weak and heavy. Both feet volas were of pains and heat. Because the patient was at the stage of high age and was sick for a long time, so the channels in the body were affected. In addition, due to damp environment in her residential place, the wind-heat dampness violated the channels and network channels. When the channels were blocked, then pains appeared. Long duration of disease violating the channels damaged the qi and blood in the body. Because of this, there were pains over the patient’s whole general body. She suffered dry throat and heat over her feet volas, which were due to deficiency of the liver and kidneys. Therefore, according to the syndrome of her tongue and pulse, her conditions could be diagnosed as Bi syndrome. Western Medicine: The patient was 64 years old. She had pains over her bone joints and muscles all over her general body. So, her condition could be diagnosed as senile joint degenerative disease. Diagnostic Differentiation: TCM: The patient’s condition is usually differentiated from wilting disease. Wilting disease has the main symptoms of weak limbs and muscle atrophy, usually without pains. So, it is easy to differentiate them. Western Medicine diagnosis: Her condition should be differentiated with rheumatoid arthritis. Rheumatoid arthritis has the main symptoms of pains, stiffness and deformation of the joints. And usually, the symptoms are symmetrical. At the early state of the disease, pains mainly happen over the joints. Therefore, there is no difficulty to differentiate them. First Diagnosis: TCM: Bi syndrome. Symptom identification: wind-heat damp Bi syndrome as well as the deficiency of the liver and kidneys. Western medicine diagnosis: Senile joint degenerative diseases. Treatment strategy and nursing: 1. Routine care of traditional Chinese internal medicine. 2. GradeⅡcare. 3. Diet of high protein and low fat. 4. Companion. 5. Pathogenesis: wind-heat damp Bi syndrome as well as the deficiency of the liver and kidneys. 6. TCM strategy: to remove wind and clear away heat, free the channels to arrest pains as well as tonify the liver and kidneys. 7. Herbal tea: one dosage a day and drink twice 8. Acupuncture and massage: once a day 9. Have more medical examination if necessary. Date: Dec. 11, 2010 Time: 9:00 am This morning, professor Zhang paid a visit to the patient. She complained of pains over her muscles and joints all over her general body for 5 years, especially pains below her lumbar portion. She felt weak over her lower limbs. When walking, she also felt pains over her knees and feet volas. She had dry throat and abdominal distention and pains. Her appetite was good, but sleep and spirit were not good. She also had constipation. Urination was good. Her tongue was red with yellowish tongue coating. Her pulse was wiry and weak. According to the theory of TCM, her condition was due to the wind-heat damp Bi syndrome as well as the deficiency of the liver and kidneys. The treatment for her condition was to remove wind and clear away heat, free the channels to arrest pains as well as tonify the liver and kidneys. Date: Dec. 12, 2010 Time: 9:00 am The patient said there was no special improvement. Feedback of examination: Glucose: 3.47 mmol/L, K: 3.44 mmol/L, Na: 117 mmol/L, CL: 78.9 mmol/L. Date: Dec. 14, 2010 Time: 9:00 am The patient said there was no evident improvement on the pains over her joints and muscles. Dry throat and abdominal distention and pains were better. Constipation improved. There were evident pressing pains on her sternomastoid muscles. There was no evident enlargement of lymph nodes over her neck. Her spirit and appetite were good. Her tongue was red with yellowish tongue coating. Her pulse was weak and wiry. Date: Dec. 18, 2010 Time: 9:00 am There was slightly improvement on the pains over her general body. She still felt dryness in her throat. Bowel movement and urination were normal. There still existed burning heat at the bottom of her feet. Her tongue was red with thin, yellowish and slightly dry tongue coating. Her pulse was wiry and thready. Date: Dec. 20, 2010 Time: 9:00 am The patient said pains over her sternomastoid muscles were evidently improved. At the same time, pains over her muscles and joints were reduced somewhat. Now, pains mainly happened on her left abdomen and ribs as well as knees. Dry throat and heat over the bottom of her feet still existed. Her tongue was red with yellowish and slightly dry tongue coating. Her pulse was thready and wiry. Date: Dec. 24, 2010 Time: 9:00 am The patient’s conditions kept changing better. In recent days, her stomach was a little bit painful than before. Her tongue was red with yellowish and slightly dry tongue coating. The root of her tongue was bristle. Her pulse was wiry and thready. Date: Dec. 28, 2010 Time: 9:00 am There were great reduction on the pains over her upper body, and pains over her lower limbs were reduced also. Dryness in her mouth and throat and heat at the bottom of her feet were alleviated. Date: Dec. 31, 2010 Time: 9:00 am The patient said pains over her sternomastoid muscles, both sides of her abdomen, her neck and shoulders dispelled. Heat at the bottom of her feet was reduced a lot. Dryness in her mouth and throat kept changing better. One thumb-width above her belly button existed evident pressing pains, particularly during the night. Pains over her lumbar part and lower limbs did not improve much recently. Her fingers were stiff at the moment of getting up; and after some movement or exercise the fingers would be more flexible. There were spontaneous jumping pains on the right side of her head. Her spirit and appetite were normal. Sleep was good. Bowel movement and urination were good. Her tongue was red with thin tongue coating. Her pulse was slightly wiry. Date: Jan. 4, 2010 Time: 9:00 am Pains over her whole general body were further alleviated. Spontaneous jumping pains on the right side of her head disappeared. No more dryness in her mouth. Heat at the bottom of her feet improved much. Stiff fingers after getting up were better. Appetite and sleep were normal. Bowel movement and urination were normal. Her tongue was slightly red with thin and white tongue coating. Her pulse was slightly wiry. Hair loss was severe since the winter season came. Date: Jan. 8, 2010 Time: 9:00 am Professor Zhang paid a visit to the patient. The patient complained of pains over her lower legs and arms, especially during the night. Sleep was not good. Pains over the inner side of her shank were reduced. She felt hard to squat. Stiff fingers after getting up were better. Her son said the patient’s right ear was deaf for more than 7 years. Dryness still existed in her throat. Her tongue was slightly red with thin tongue coating. Her pulse was wiry and thready. Date: Jan. 12, 2010 Time: 9:00 am The patient said pains over her lumbar part and arms as well as outer side of her lower limbs were reduced. She could sleep for about 6 hours. Other conditions liked days before without any special change. Date: Jan. 16, 2010 Time: 9:00 am Rodaba complained of pains occurring especially in the night in the recent days. Date: Jan. 20, 2010 Time: 9:00 am The patient said pains were not reduced evidently in recent days. Appetite and sleep were just ok. Bowel movement and urination were normal. Date: Jan. 24, 2010 Time: 9:00 am Today, the patient said pains over her upper limbs were reduced. Sleep was good, about 6 hours. Pains of her lower limbs were reduced a little bit. Appetite and spirit were normal. Her tongue was slightly red with thin and white tongue coating. Her pulse was slightly wiry. Date: Jan. 28, 2010 Time: 9:00 am The patient’s conditions were stable without evident improvement. Her appetite and spirit were good. Her sleep was not good. Her tongue was red with thin tongue coating. Her pulse was slightly wiry. Date: Jan. 31, 2010 Time: 9:00 am The patient’s condition was stable recently. Date: Feb. 3, 2010 Time: 9:00 am Sodaba decided to leave the hospital tomorrow. After nearly two months’ TCM comprehensive treatment here in our hospital, she achieved some improvement in her conditions. With the TCM treatment method of removing wind and clearing away heat, freeing the channels to arrest pains as well as tonifying the liver and kidneys, pains over her whole general body were reduced somewhat. Night sweating, heat at the bottom of her feet and abdominal pains were improved much. Dryness in her throat still existed. Appetite, spirit and sleep were normal. Urination and bowel movement were normal also. Doctor’s advice after leaving hospital: 1. Avoid wind-cold, maintain good moods. 2. Take herbal medicine back for continuing treatment.
3. Keep doing functional exercises.