Brief Summary: On April 27, 2015, Mr. Pan Rensheng, came from Zhongfang County, who had been suffering from gouty arthritis for more than 5 years and being severe for 7 days. He was hospitalized in our hospital. He achieved some improvement after 18 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization

Name: Pan Rensheng                      Sex: Male

Age: 61                                             Marital Status: Married

Nationality: China                            Date of Admission: Apr. 27, 2015

Companion: Alone

First Medical Record

Date: Apr. 27, 2015                            Time: 14:00 p.m.

This 61-year-old man had been suffering from pains over his body for more than 5 years, being severe for 7 days. He was hospitalized in our hospital as a patient with gouty arthritis for TCM treatment at 14:00 p.m. on Apr. 27, 2015.

Essential for Diagnosis:

1. The patient said he had the pains of the joints of his whole body after overwork 5 years ago. He felt distent pains of his joints, weakness, heavy and tired. He bought the medicine from the pharmacy by himself, the condition got better. Recent years, the pains repeatedly attacked. After the physical work, the pains got worse. After taking the rest, the pains relieved. When the pains appeared, he felt weak, sore, and the movement of joints limited, especially his upper joints. There was no allergy history of any food or any medicine.

2. When Mr. Pan came to our hospital, the pains attacked again 7 days ago. The pains ran over his body, especially his shoulder joints, and the joints movement was limited. After overwork, the pains got worse. When the weather was cold or in winter, the pains became severe. He felt tired. He felt sore and distent over his four limbs. His appetite was good. When he took the cold and spicy food, he had the symptoms of stomachache, abdominal distension and diarrhea. His urination was normal.

3. T: 36.2°C   R: 20 times/minute    P: 74 times/minute   BP: 90/60 mmHg

The patient grew normally. He was alert and cooperative. He had chronic sick facial complexion. There was no sign of yellow sclera or yellowish skin. There was no enlargement on the superficial lymph node of his whole body. Facial features were normal without masses. There were pressing pains over ter top of his head and tempora bone. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. His neck was soft without resistant. His trachea was symmetrical. There was no enlargement over his thyroid. The jugular vein was of no engorgement. His chest was symmetrical without deformity. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 74 times per minute. Heart rate was regular with no murmurs. His abdomen was soft with no pressing pains and rebound tenderness. There was no sign of deformity over his spine. There were pressing pains over his shoulder joints and around his spine. The meningeal irritation sign was negative. There were no pathological reflections, but the physiological reflections existed. The tongue body was dark red with white and thin coating. The pulse was deep, string and slippery.

Diagnostic Differentiation:

TCM:  Impediment