Brief Summary: On March 19, 2013, Mr. Pan Cungao, from the village of Longjing near our hospital, who had been suffering from pains over his left lower limb for more than 4 months, was hospitalized in our hospital. He achieved great improvement after 21 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization 

Name: Pan Cungao                              Sex: Male

Age: 73                                                 Marital Status: Married

Nationality: China                                Date of Admission: March 19, 2013

Companion: Alone 

First Medical Record 

Date: Mar. 19, 2013                                Time: 10:00 a.m. 

This 73-year-old man had been suffering from pains over his left lower limb for more than 4 months. He was hospitalized in our hospital as a patient with rheumatic arthritis for TCM treatment at 10:00 a.m. on March 19, 2013 

Essential for Diagnosis: 

1. The patient had been suffering pains over his left lower limb for more than 4 months. He had medical history of hypertension and cataract surgery. 

2. When Mr. Pan came to our hospital, he suffered joint pains and numbness over his left lower limb. He also suffered back pains and when the weather changed, pains were getting worse. He did not have dizziness or headache. Appetite was good. Sleep was normal. Urine was yellowish, with slight quantity. Bowel movement was normal. His spirit was normal. He sometimes felt dryness in his mouth.   

3. T: 36.2C   R: 20 times/minute    P: 74times/minute   BP: 154/76mmHg 

4. The patient had normal spiritual activity and natural facial expression. There were many pressing pain points over his left-side back and lower limbs. Elevation test of straight right leg (+). Other test results were normal. His tongue was red, with yellowish tongue coating. His pulse was wiry but powerful. 

Diagnostic Differentiation: 

TCM:

The patient suffered joint pains over his left lower limb for 4 months, which should be in the category of impediment type in TCM. Besides, the patient being in high age caused deficiency of the liver and kidneys. He used to have the medical history of hypertension. The liver-yang was a little hyperactive, and his pulse was wiry and powerful. The stagnation of blood blocking the channels led to joint pains and numbness over his left lower limb, as well as back pains. According to the above analysis, his condition should be impediment symptom caused by hyperactivity of liver-yang as well as the stagnation of blood blocking the channels. 

Western Medicine diagnosis: 

There were joint pains and numbness over his left lower limb for 4 months. He also suffered back pains, and when the weather changed, his condition became severe. There were many pressing pain points over his left lower limb.

First Diagnosis: 

TCM: impediment pattern.

Symptom identification: Excessive rising of liver-yang and the stagnation of blood blocking the channels.  

Western medicine diagnosis: Rheumatic Arthritis

Treatment strategy and nursing: 

1. Routine care of traditional Chinese internal medicine. 

2. Grade care.  

3. Diet of low salt and low fat. 

4. Pathogenesis: Excessive rising of liver-yang and the stagnation of blood blocking the channels.  

5. TCM strategy: calming liver wind, reinforcing the liver and kidneys as well as promoting the circulation of blood to remove the blood stasis. 

6. Herbal tea: one dosage a day and drink twice 

7. Acupuncture and massage: once a day 

8. Have more medical examination if necessary.