March 9, 2013, Mr. S, from India, who had been suffering psoriatic arthritis
On March 9, 2013, Mr. S, from India, who had been suffering psoriatic arthritis, accompanied by pains over his vertebral column for one year, was hospitalized in our hospital. In the recent 3 months, his condition became severe. He achieved great improvement after two weeks TCM treatment in our hospital with the help of herbal tea, acupuncture and massage.
Record of Hospitalization Name: Mr. S Sex: Male Age: 18 Marital Status: Unmarried Nationality: India Date of Admission: Mar. 9, 2013 Companion: His mother
First Medical Record
Date: Mar. 9, 2013 Time: 10:00 a.m. This 18-year-old boy had been suffering from psoriatic arthritis, accompanied by pains over his vertebral column for one year. The patient was hospitalized in our hospital for TCM treatment at 19:30 p.m. on March 8, 2013. Essential for Diagnosis:
1. The patient had been suffering from psoriatic arthritis, accompanied by pains over his vertebral column for one year. His condition became severe in the recent 3 months.
2. The patient complained that he suffered from stabbing pains over his vertebral column of his neck part, chest part and lower back part after fatigue and sudden-changed weather. When pains happened, there were reddish, edema and heat. He went to a hospital in New Delhi for examination. His condition was diagnosed as psoriatic arthritis and AS (Ankylosing Spondylitis), according to his examination report and his clinical manifestations. Doctors gave him some western medicine for killing his pains, but the effect was not so good. He used to do operations for 4 times for the problem of hypospadias, but not succeeded. He had the medical history of enteritis for 2 years.
3. When Mr. S came to our hospital, she suffered from pains over his neck, lumbar part and caudal vertebra，accompanied by reddish, swelling and heat pains over his shoulders, knees and chest part occurring 2-3 times every day and lasting for about 1-1.5 hours, and then pains alleviated. He suffered stabbing pains and felt burning and swelling sensation. When the weather changed and he felt fatigued, his condition became more severe. When pains happened, he felt hardness of his body and felt hard to make movements. He felt dryness in his mouth and had running nose, sore throat and coughing. He suffered occasional gastric distension and gastric pains. His spirit was not good. Appetite was bad. Sleep was normal. He had frequent and urgent urination. When urinated, he felt painful and burning sensation over his urethral meatus. He had night urination for 8 times per night, with less quantity each time. His bowel movement was normal, with once a day.
4. T: 36.6°C R: 20 times/minute P: 97 times/minute BP: 124/84 mmHg
5. The patient grew normally with standard body shape. His spirit activity was not good. There was no enlargement of her lymph gland and thyroid gland. Rhythm of his heart was 97 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. There were percussion pains over his kidneys parts. There were pressing pains over his liver parts. There were obvious pressing pains over his shoulder muscles and slight pressing pains over his knees. There was no swelling symptom over his knees. His tongue was red, with thin and yellowish tongue coating and cracks over the tongue surface. His pulse was thready and rapid.
Diagnostic Differentiation: TCM: The patient had the main symptoms of reddish, swelling and burning pains over his vertebral column and shoulders. He also felt stiffness of his body. From the view of TCM, his condition should be caused by pathogenic heat, wind and dampness invading his channels and joints. Channels and joints were blocked, and then pains happened. The stagnation of pathogenic wind could cause fever; then, the patient felt stiff over his joints and felt burning sensation when pains happened. Pathogenic wind wanders a lot, so his upper limb joints were of severe pains and the locations of pain points were unstable. He had frequent, urgent and painful urination, which was caused by pathogenic damp and heat wandering to the lower energizer. According to his tongue and pulse symptoms, his condition should be arthritis and heat stranguria. Western Medicine diagnosis: 1. Pains over his vertebral column and joints for 1 year, and developed into severe condition for 3 months. 2. There were percussion pains over his kidneys parts. There were pressing pains over his liver parts. There were obvious pressing pains over his shoulder muscles and slight pressing pains over his knees. First Diagnosis: TCM: 1. Arthritis Symptom identification: impediment due to wind, dampness and heat 2. Heat stranguria
Symptom identification: damp heat sinking
Western medicine diagnosis:
1. Psoriatic arthritis
2. Lower urinary tract infection 3. Second degree fatty liver Treatment strategy and nursing: 1. Routine care of traditional Chinese internal medicine.
2. Grade Ⅱ care.
3. Common diet. 4. TCM strategy: dispelling wind and eliminating dampness and freeing the channels as well as relieving pains. 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: Mar. 10, 2013 Time: 09:00 a.m.
Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient complained that there were stabbing pains over his neck, chest, the lower back and vertebral joints. He felt burning sensation when pains happened. He also felt painful and stiff over his shoulders. He felt dryness in his mouth. He had running nose. He also had sore and itchy throat. He coughed occasionally. He had frequent, urgent urination. He had night urination 7-8 times. The quantity of urine was less with yellowish color. His spirit was not good. His appetite and sleep were normal. His tongue was red with thin, greasy and yellowish tongue coatings. His pulse was rapid and thready. There were pressing pains over his liver part. The border of dull resonance of his liver was moving down. His urinary meatus was reddish and painful. From the view of TCM, Dr. Ming thought that the case of the patient could be diagnosed as arthritis and heat stranguria, due to damp heat being sinking. The treatment strategy for it would be to dispel wind and eliminate dampness and free the channels as well as relieve pains.
Date: Mar. 11, 2013 Time: 09:00 a.m.
The patient said that he suffered burning joint pains once last night around 21:00 p.m., and the pains lasted for almost 1.5 hours. He felt that the pains were less severe than before. Running nose, itchy throat, sore throat and coughs were all changed better. He still had urgent, frequent urination. He also had burning sensation when urinated. Doctors advised him to drink more water.
Date: Mar. 12, 2013 Time: 09:00 a.m.
The patient said pains over his lower back part and chest part were reduced somewhat yesterday. He suffered neck pains yesterday, lasting for about 40 minutes. He still had slightly dry cough. The symptoms of frequent urination, urgent urination and odynuria were almost gone. His tongue was red with thin, yellowish and greasy tongue coatings. His pulse was thready and rapid.
Date: Mar. 15, 2013 Time: 09:00 a.m.
The patient said that the symptoms of frequent urination, urgent urination and odynuria were completely gone. He said there were obvious pressing pains over his right shoulder. The pains went from the inside of his forearm along the Lung Meridian of Hand-Taiyin, lasting for around 20 minutes. There were neck pains once, lasting for about 40 minutes. No pains happened over his chest part and lower back part. He had dry cough with no phlegm. His spirit was good. His appetite and sleep were normal. Urination and bowel movement were normal. His tongue was red, with thin, yellowish and greasy tongue coatings. His pulse was thready and rapid.
Date: Mar. 17, 2013 Time: 09:00 a.m.
The patient said he did not suffer any pains over his bone joints these days. There was no special discomfort. Date: Mar. 19, 2013 Time: 09:00 a.m. The patient said in the recent 3 days, he felt well. He did not feel any pains over the bone joints of his whole general body. There was no special discomfort. Date: Mar. 22, 2013 Time: 09:00 a.m. The patient said pains over his vertebral joints, shoulders and knees were gone. He felt very well right now. His spirit was good. Appetite and sleep were normal. Urination and bowel movement were normal. He decided to leave our hospital today. Doctor’s advice after leaving hospital: 1. Avoid wind-cold, maintain good moods, and take care of the diet. 2. Take herbal medicine back for continuing treatment.
3. Avoid living damp area and do some proper exercise.