2014, Smitha, came from India, who suffered from impediment Syndrome

On Mar. 10, 2014, Smitha, came from India, who suffered from impediment Syndrome. She had the pains over her whole muscles and the joints of her four limbs for 15 years. She was hospitalized in our hospital. She got 50% improvement after 77 days TCM treatment.

Record of Hospitalization

Name: Smitha                                                                  Sex: Female

Age: 39                                                                           Marital Status: Married

Nationality: India                                                            Date of Admission: Mar. 10, 2014

Companion: her husband

First Medical Record

Date: Mar. 7, 2014                    Time: 14:00 pm

Smitha, female, 39 years old, had suffered from pains over her whole muscles and the joints of her four limbs for 15 years. The patient was hospitalized in our hospital with “impediment Syndrome” for TCM treatment at 21:30 pm on Mar. 10, 2014.

Essential for Diagnosis:

1. The patient had suffered from pains over her whole muscles and the joints of her four limbs for 15 years. She was diagnosed with hypertension in 2012. There was no medicine and food for her to get allergy response.

2. The patient had pains over her whole muscles and the joints of her four limbs for 15 years, especially her knee-joints and her leg muscles. The pains were accompanied with tightness. All her muscles were stiff. Sometimes her knee-joints were red with burning sensation and slight edema. There was numbness of her four limbs. When the weather got cold, the pains got worse. While the hot compression could relieve the pains. Her fingers were stiff in the morning, but after exercises the stiffness relieved. She just can walk 10 to 15 meters. If she walked more than 15 meters, her knee-joints had severe pains. She could not put her legs down for a long time. If she put her legs down, her feet skin would get blue. Sometimes she had pains over her waist and hip. She was afraid of cold. When we touched her four limbs, the limbs were cold. And sometimes she had short breath, chest oppression and dizziness. There was sweating at night. Her menstrual cycle was normal, but with blood clots. Before and after her menstruation all the pains got worse. And sometimes she had edema and stomach distension. Her sleep was good. Her bowel movement and urination were normal. Her tongue was dark purple, especial the margins of her tongue. There was blood stasis below the tongue. The tongue coating was white and thin. The pulse was thin and unsmooth.

3. T: 36.4°C   R: 20 times/minute    P: 74 times/minute   BP: 122/78mmHg

The patient had normal growth. She had slight overweight body. Her spiritual activity was normal. There was no yellow skin or yellow sclera over her whole body. There was no enlargement over her superficial lymph node. Her neck was soft. Her trachea was symmetrical. There were no blood stasis and pseudomembrane in her throat. The jugular vein was of no engorgement. Her chest was also symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of her heart was 74 times per minute. Heart rate was regular with no murmurs. Her abdomen was soft without pressing pains and rebound tenderness. There was no sign of deformity over her spine and four limbs. The straight leg rising test showed that the result of her legs was positive. The results of figure of “4” test were also positive in both of her legs. There were no other pathological reflections. Her tongue was dark purple. There was ecchymosis below the tongue. The tongue coating was white and thin. The pulse was thin and unsmooth.

3. Examination: MRI: L4- L5 bulged; ESR: 53 mm/h

Diagnostic Basis:

TCM: Impediment syndrome

Western Medicine: 1) Fibromyalgia syndrome(Fatigue syndrome)

                                 2) Osteoarthritis

                                 3) Rheumatic arthritis

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ care, companion, and common diet.

3. To apply for the three routine inspection, ESR examination, rheumatoid factors, anti-O, the function of kidneys and liver, electrocardiogram (ECG), etc.

4. Herbal tea: one dosage a day and drink twice; let soaking by herbal tea, there times a day, twenty minutres each time.

5. Acupuncture and massage: once a day

6. Avoid wind and cold, relax mind, regulate living timetable and adjust diet.

Date: Mar. 12, 2014                                    Time: 10:00 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient had pains over her whole muscles and the joints of her four limbs for 15 years, especially her knee-joints and her leg muscles. The pains were accompanied with tightness. All her muscles were stiff. Sometimes her knee-joints were red with burning sensation and slight edema. There was numbness of her four limbs. When the weather got cold, the pains got worse. While the hot compression could relieve the pains. Her fingers were stiff in the morning, but after exercises the stiffness relieved. She had waist pains. She felt dry mouth. She preferred warm drinks. She was afraid of cold. When we touched her four limbs, the limbs were cold. If she put her legs down for a long time, her feet skin would get blue. And sometimes she had short breath, chest oppression and dizziness. There was sweating at night. Her sleep was not good. Her menstrual cycle was normal, but with blood clots. Before and after her menstruation all the joints pains got worse with edema and stomach distension. Her bowel movement and urination were normal. Her tongue was dark purple, especial the margins of her tongue. There was blood stasis below the tongue. The tongue coating was white and thin. The pulse was thin and unsmooth. Dr. Ming diagnosed the disease should be arthritis according to the TCM four diagnostic methods.

Date: Mar. 13, 2014                                    Time: 10:00 a.m.

The patient felt that her waist pains got worse. The other symptoms were the same. And this morning we got the results of the test: Gran% 72.6↑; Het 35.7% ↓; Vc +-; SG 1.030; PRO+ 1; URO+1; TP55 ↓; A/G 2.67 ↑; ESR 51 ↑.

Date: Mar. 17, 2014                                    Time: 9:00 a.m.

The patient said the stiffness of her fingers in the morning was improved. The pains were the same. Her tongue was still dark purple, but the margins of her tongue were better. The tongue coating was white and thin. The pulse was deep, string-like and unsmooth.

Date: Mar. 20, 2014                                    Time: 9:00 a.m.

The patient said her waist pains got improvement. And the pains of her knee-joints also relieved. Her walking and range of motion of her knees were better. But the pains of her whole body were the same, refusing to pressure. Her sleep and appetite were normal. And her urination and bowel movement were good. Her tongue was purple with white and thin coating. The pulse was deep and unsmooth.

Date: Mar. 23, 2014                                    Time: 9:00 a.m.

The patient said the pains on her legs got worse because she walked for a long time yesterday. The pains over her waist relieved. The other symptoms were the same.

Date: Mar. 26, 2014                                    Time: 9:00 a.m.

The patient said she had palpitations and short breath without chest pains this morning. But if she stayed in bed, the symptoms relieved. The burning sensation of her knee-joints was better. And she could walk longer.

Date: Mar. 29, 2014                                    Time: 9:00 a.m.

The patient said the palpitations and short breath disappeared. When she woke up this morning, she felt her palms were burning. And last two nights she had sweating. And the cold sensation of her limbs was obviously improved. She still felt dry mouth. She preferred warm drinks. Her sleep was good. Her urination and bowel movement were normal.

Date: Apr. 1, 2014                                    Time: 9:00 a.m.

The patient said that the waist pains were obvious during her period. Her menstruation came yesterday. But this morning there were no burning sensation of her palms and dry mouth. Her appetite was normal. And there was no sweating at night. Her tongue was pale with white and thin coating. The pulse was deep.

Date: Apr. 9, 2014                                    Time: 15:00 p.m.

The vital signs of the patient were stable. The patient said the skin of her lower limbs still had tenderness, but it was better than before. The color of the veins became lighter. And the range of the blueveins was obviously narrowed.

Date: Apr. 12, 2014                                    Time: 11:00 a.m.

The vital signs of the patient were stable. But she had abdominal distension. Doctor adjusted her formula.

Date: Apr. 16, 2014                                    Time: 10:00 a.m.

The patient said there was no power. She felt tired. The abdominal distension improved. The result for the pains of her elbow joints was not good. Although she still had the tenderness over her lower limbs. But it was obviously improved.

Date: Apr. 22, 2014                                    Time: 9:00 a.m.

The patient said the pains of her knee-joints got worse. There were dry mouth and sweating. The pains of her elbow joints were improved. She had insomnia.

Date: Apr. 25, 2014                                    Time: 9:00 a.m.

The patient said the pains of joints got worse during her period with slight dizziness. The menstrual quantity was much more than before. And there were some clots. The color was dark red. This afternoon we got the result of the examination. Gran 7.2×10⁹ ↑; Gran 74.7% ↑; HCT 34.7% ↓; HDL0.32 ↓; ALP 142 ↑; r- GT 66 ↑; ALT 41 ↑; TP 56 ↓; GLB 13 ↓; A/G 3.31 ↓; CRE-KU47 ↓; 2-HBDH 41 ↓.

Date: Apr. 28, 2014                                    Time: 9:00 a.m.

The patient said the pains of her knee-joints were relieved. And the pains of her upper limbs joints were obviously improved. There were no dizziness and palpitations. Her appetite and sleep were good. Her tongue was slightly dark with white and thin coating. Her pulse was deep and wiry. There is dry throat. Sometimes she had sweating. Her urination and bowel movement were normal.

Date: May 01, 2014                                    Time: 9:00 a.m.

The vital signs of patient were stable. There is no obvious change.

Date: May 05, 2014                                    Time: 9:00 a.m.

The patient said the pains of her upper limbs joints were better than before. And the pains of her knee-joints were obviously relieved, as well as her waist pains. There were no dizziness and palpitations. Her appetite and sleep were good. Her tongue was slightly dark with white and thin coating. But the bruise of the edge of her tongue was getting slighter. Her pulse was deep and wiry. There was dry throat. Her urination and bowel movement were normal. Dr. adjusted her formula.