2014, Nedezhdazuyece, came from Russia, who suffered from arthritis
On Feb 24, 2014, Nedezhdazuyece, came from Russia, who suffered from arthritis. She had the wandering pains of the joins for 3 years. The joints of the whole body had pains, and the pains were wandering. Her neck and shoulders had pains, the pains were worse if the weather was cold. The finger joints were painful with burning sensation. She had headache in left side of his head. Her arms always felt numbness, especially her right arm. And her left rib had pains. Sometimes she had stomachache, fever, nausea and hiccup. After the meal, the stomachache would be relieved. And sometimes she had tinnitus. The color of urine was slightly yellow. She had constipation, once every 3 to 4 days. Her mood was up and down a lot. She was hospitalized in our hospital. She had great improvement after 19 days TCM treatment.
Record of Hospitalization Name: Nedezhdazuyece Sex: Female Age: 52 Marital Status: Married Nationality: Russia Date of Admission: Feb.24, 2014 Companion: Nobody First Medical Record Date: Apr. 17, 2014 Time: 11:00 am Nedezhdazuyece, male, 52 years old, had suffered from impediment pattern for 3 years. She was hospitalized in our hospital as a patient with “wandering pains of the joints” for TCM treatment at 20:00 pm on Feb. 24, 2014. Essential for Diagnosis:
1. History of Disease: The patient had the wandering pains of the joints for 3 years. She was diagnosed with arthritis deformans at the local hospital in 2010. She had chronic gastritis in 1998. She had chronic pancreatitis and cholecystits in 2002. She had thyroid cyst in 2012, and she had ovary cyst in 2013.
2. When the patient came to our hospital, she had the wandering pains of the joints for 3 years. The joints of the whole body had pains, and the pains were wandering. Her neck and shoulders had pains, the pains were worse if the weather was cold. The finger joints were painful with burning sensation. She had headache in left side of his head. Her arms always felt numbness, especially her right arm. And her left rib had pains. Sometimes she had stomachache, fever, nausea and hiccup. After the meal, the stomachache would be relieved. And sometimes she had tinnitus. The color of urine was slightly yellow. She had constipation, once every 3 to 4 days. Her mood was up and down a lot. 3. T: 36.5°C R: 20 times/minute P: 80 times/minute BP: 112/74mmHg The patient had normal growth, physique and spiritual activity, while with chronic disease face. She cooperated with doctors when the physical examinations were made. There was no enlargement over her superficial lymph node. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. The two eyeballs were slightly propped. The thyroid was enlarged without pressing pains. The back of her neck had nodules, and there were obvious pressing pains. When doctor pressed the left nodule, she had headache in right side of her head. The 1 and 2 chest vertebral body had obvious pressing pains. To examine her heart and lungs, the result showed (-). Her abdomen was soft. There were obvious pressing pains in her gastral cavity, but without rebound tenderness. There were pressing pains from the second lumbar vertebra to the first sacral vertebra. The straight leg rising test showed that the result of her left leg was positive. The results of figure of “4” test were positive in both of her legs. There was no sign of deformity over her spine and four limbs. There were no pathological reflections, but the physiological reflections existed. Her tongue body was thick with white and thin coating. The pulse was taut and slippery. According to her right pulse condition, she had deficiency of spleen qi, and the pulse was weak with deep-pressing, while her left pulse condition was powerful and strong. 4. Examination: No. Diagnostic Basis: TCM: impediment pattern Western Medicine: arthritis deformans Treatment strategy and nursing: 1. Routine care of traditional Chinese internal medicine.
2. Grade Ⅱ care.
3. Common diet.
4. To apply for the three routine inspections, and the related examinations: the function of kidneys and liver, ESR, rheumatoid factors, anti-O, etc.
5. Herbal tea: one dosage a day and drink twice
6. Acupuncture and massage: once a day
7. Avoiding from wind and cold, regulating living timetable, relaxing mind and adjusting the diet. Date: Feb. 26, 2014 Time: 9:00 a.m. Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient suffered from the wandering pains of the joins for 3 years. The joints of the whole body had pains, and the pains were wandering. Her neck and shoulders had pains. The pains were worse if the weather was cold. The finger joints were painful with burning sensation. She had headache in left side of her head. Her arms always felt numbness, especially her right arm. And her left rib had pains. Sometimes she had stomachache, fever, nausea and hiccup. After the meal, the stomachache would be relieved. And sometimes she had tinnitus. The color of urine was slightly yellow. She had constipation, once every 3 to 4 days. Her mood was up and down a lot. Body check up: The two eyeballs were slightly propped. The thyroid was of enlargement without pressing pains. The back of her neck had nodules, and there were obvious pressing pains. When doctor pressed the left nodule, she had headache in right side of her head. The 1 and 2 chest vertebral body had obvious pressing pains. To examine her heart and lungs, the result showed (-). Her abdomen was soft. There were obvious pressing pains in her gastral cavity, but without rebound tenderness. There were pressing pains from the second lumbar vertebra to the first sacral vertebra. The straight leg rising test showed that the result of her left leg was positive. The results of figure of “4” test were positive in both of her legs. There was no sign of deformity over her spine and four limbs. There were no pathological reflections, but the physiological reflections existed. Her tongue body was thick with white and thin coating. The pulse was taut and slippery. According to her right pulse condition, she had deficiency of spleen qi, and the pulse was weak with deep-pressing, while her left pulse condition was powerful. Dr. Ming diagnosed the disease should be arthritis. Date: Feb. 27, 2014 Time: 9:00 a.m.
This morning we got the results of the examination: Blood-R: WBC 3.6×109 /L; Urine-R: Vc ＋3; PRO＋－; Stool-R: (-) ; Blood-LF: DB 1.6 umol/L; SPS: (-); HDL 0.51 mmol/L↓; 2- Hbdh 70 u/L ↓. ESR:21 mm/h ↑; Anti-O (-); rheumatoid factors:(-). The leukocyte was lower than normal. ESR was slight fast.
Date: Feb. 28, 2014 Time: 9:00 a.m. The patient said she still had nausea this morning. There were much more sleeping. The other symptoms were the same. Date: Mar. 4, 2014 Time: 9:00 a.m. The patient said she still had pains. Sometimes he had waist pains. But the sour regurgitation and nausea disappeared. Her tongue was dark red with white and thin coating. The pulse was taut and slippery. The right pulse condition was the same. But the left one is better. Doctor adjusted the formula. Date: Mar. 5, 2014 Time: 9:00 a.m.
The patient said she had headache, and she had hot sensation on her head, while her feet were cold. Her tongue was reddish with yellow and thin coating. The pulse was floating, taut and rapid. Her body temperature was 37.2℃. Doctor asked to do the blood routine examination. The doctor prescribed the Radix Isatidis granules (one pack once, three times a day).
Date: Mar. 5, 2014 Time: 15:00 p.m. The result of blood routine examination was normal. The patient said she was allergic to the antibiotics, so she refused to take the medicine Chlorphenamine maleate capsules. Date: Mar. 6, 2014 Time: 9:00 a.m. The patient said she got cough with yellow phlegm, but without fever. There was no headache. She did not mind the cold. The tongue was reddish with white coating. The pulse was floating and taut. Doctor adjusted the formula for her cough and phlegm. Date: Mar. 9, 2014 Time: 9:00 a.m. The patient said her cough had been relieved. And the back pains were improved. But she still felt tired without power. The tongue was red with white and thin coating. The pulse was deep and wiry. Date: Mar, 11, 2014 Time: 9:00 p.m. The patient said she had pains in her 12nd rib-side when she took deep breathing. But there were no obvious pressing pains. Last night she had sweating at night. And she felt her body was hot, but in her palms and soles she felt cold. Doctor considered the patient’s age, and she had menstrual disorder. It should be the symptoms of menopause. So doctor asked the patient to keep good mentality and do some proper exercises. Date: Mar, 14, 2014 Time: 9:00 p.m. The patient decided to leave our hospital. Conditions at discharge: The joint pains had been improved. And there were no burning sensation and pains in her finger joints. And her headache and stomachache were obviously relieved. Doctor’s advice after leaving hospital: