2015, Liao henggang, from police station, pains over his left knee-joint for one year
On Jan. 08, 2015, Liao henggang, from police station of Zhongfang County, who had been suffering wind-damp impediment syndrome, pains over his left knee-joint for one year, and the pains became worse one week ago. He was hospitalized in our hospital. He achieved great improvement only after 11 days TCM treatment with the help of acupuncture, herbal tea and massage in our hospital.
Record of Hospitalization
Name: Liao henggang Sex: Male
Age: 43 Marital Status: Married
Nationality: China Date of Admission: Jan. 08, 2015
Companion: Alone
First Medical Record
Date: Jan. 08, 2015 Time: 14:00 p.m.
This 43-year-old man had been suffering from impediment syndrome. He had pains over his left knee-joint for one year. The patient was hospitalized in our hospital for TCM treatment at 14:00 p.m. on Jan. 08, 2015.
Essential for Diagnosis:
1. The patient had been suffering from pains over his left knee-joint for one year. And the pains became worse for one week. Because the living environment in the army was not so good when he was young and the patient did not pay attention to keep warm. One years ago he had sore pains over his left knee-joint caused by cold, and he had movement limitation of his left leg. He accepted some treatment for this condition, and the symptoms were relieved, but the pains will be worse when the weather became cold.
2. When he came to our hospital, he had pains over his left knee-joint, accompanied with swelling, pains. The ability of walking up and down stairs and bending his knee were limited. And the pain will be worse when the weather became cold. He also had back pains. His appetite and sleep were good. And his bowel movement and urination were normal. The patient had been suffering from fatty liver for 3 years, yet there was no clinic symptoms. There were no allergy history of any medicine or foods. The tongue body was reddish with thin and white tongue coating. His pulse was wiry, thin and tight.
3. T: 36.4°C R: 22 times/minute P: 85 times/minute BP: 120/80mmHg
The patient had normal growth, physique and spiritual status, while with acute disease face. The movement of his legs was limited. He cooperated with doctors when the physical examinations were made. There was no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. His head and the five sense organs were normal with no deformity and masses. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. His ears were normal without any discharge. And His hearing was normal, the bilateral mastoid had no pressing pains. His nose was normal, with no stuffy nose and discharge. His lips was reddish. There was no congestion in his throat or no enlargement over his tonsil. His neck was soft with no resistance. There was no distention of jugular vein. This thyroid was normal. His trachea and chest were symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 85 times per minute. Heart rate was regular with no murmurs. His abdomen was soft with no pressing pains and rebound tenderness. The left knee-joint was of swelling and pains. There was the movement limitation when he climbed up and down stairs or bent his knee. The meningeal irritation was negative. There were no pathological reflections, but the physiological reflections existed.
Diagnostic Differentiation:
TCM: 1. impediment syndrome
2. Wind-damp impediment syndrome
Western Medicine diagnosis:
Rheumatic Arthritis
Treatment strategy and nursing:
1. Routine care of traditional Chinese internal medicine.
2. Grade Ⅱ care.
3. Light diet, avoid wind and cold, have a good mood, keep warm.
4. Complete the related examination, three routine inspections, the functions of kidneys and liver and blood sugar.
5. Herbal tea: one dosage a day and drink twice
6. Acupuncture and massage: once a day
Date: Jan. 09, 2015 Time: 11:30 a.m.
Dr. Luo Jundong, doctor-in-charge, paid a visit to the patient. The patient said he had pains over his left knee-joint, accompanied with swelling and pains. The ability of walking up and down stairs and bending his knees were limited. And the pains will be worse when the weather became cold. He also had back pains. His appetite and sleep were good. And his bowel movement and urination were normal. Dr. Luo made the treatment strategy and treatment plan.
Date: Jan. 10, 2015 Time: 11:30 a.m.
When the doctor visited the patient this morning, the patient said pains over his left knee-joint were obviously reduced. And the ability of bending his knee was better. While he still had back pains. His sleep and appetite were good. And his bowel movement and urination were normal.
Date: Jan. 11, 2015 Time: 11:30 a.m.
The patient said the swelling over his left knee-joint disappeared. And the pains relieved. Yet the back pains were the same. This morning we got the results of the related examination. HGb 172.9 G/L ↑; Urobilinogen + -; Bilirubin +1; Urine Protein + -; The function of liver: GLB 17.9 g/l↓, /g 2.87 ↑, ALT 731U/L ↑, TBA 21 UMOL/L ↑, TG 1.75MMOL/L ↑, LDL 4.52MMOL/L. Because the patient had fatty liver for 3 years, it was confirmed by the test results. ESR and RF were normal.
Date: Jan. 14, 2015 Time: 11:30 a.m.
The patient said that the pains over his left knee-joint almost disappeared. Continued to take the same formula.
Date: Jan. 17, 2015 Time: 10:30 a.m.
The vital signs of patient were stable. The patient said his condition was greatly improved.
Date: Jan. 19, 2015 Time: 10:30 a.m.
The patient said that the pains and swelling over his left knee-joint disappeared, and he can walk up and down the stairs and bend his knee flexibly. And his back pains also had great improvement. Because his recovery the patient decided to leave the hospital today.
Doctor’s advice after leaving the hospital:
1. Avoid wind-cold and keep a good mood.
2. Take herbal medicine back for consolidating the treatment.
3. Pay attention to keep warm for his knee-joints.