Brief Summary: On May 30, 2013, Ms. Zhou Lianxiang, from Zhongfang County, who had been suffering from pains of the joints over her whole body for more than 13 years and being severe for 1 year, was hospitalized in our hospital. She achieved some improvement after 17 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization

Name: Zhou Lianxiang                           Sex: Female

Age: 56                                                  Marital Status: Married

Nationality: China                                Date of Admission: May 30, 2013

Companion: Alone

First Medical Record

Date: May 30, 2013                                Time: 13:00 p.m.

This 56-year-old woman had been suffering from pains of the joints over her whole body for more than 13 years. Her condition became severe for one year. She was hospitalized in our hospital as a patient with rheumatic arthritis for TCM treatment at 13:00 p.m. on May 30, 2013

Essential for Diagnosis:

1. The patient had been suffering pains of the joints over her whole body for more than 13 years. Her condition became severe for one year. She had allergy history of any food or medicine.

2. When Ms. Zhou came to our hospital, she suffered pains of the joints of her whole body, especially the knee joints. When the pains happened, it liked needle-pricking. There was heat over the joints. Such condition became severe during the night. There were deformation signs over her four limbs and knee joints. It was not flexible for her to bend or extend her foot. She walked slowly with difficulty. There were pains over the top of her head. There was hyperemia sign over her eyes. There was skin ecchymosis with purple color over the skin of her limbs. She felt dryness and bitterness of her mouth. She was afraid of coldness. She liked hot drinks. Appetite was not good. Her sleep was not good. Urination and bowel movement were normal.

3. T: 36.4C   R: 20 times/minute    P: 80 times/minute   BP: 120/60 mmHg

4. The patient had normal spiritual activity and painful facial expression. There were no sign of yellow sclera or yellowish skin. There was hyperemia sign over her eyes. There was skin ecchymosis with purple color over the skin of her limbs. There was no enlargement over her superficial lymph node. Her neck was stiffness, with less flexibility. There was no enlargement on her thyroid gland. Rhythm of his heart was 80 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. Her abdomen was soft, without any pressing pains, rebound tenderness or enclosed mass. There were deformation and enlargement over her limbs and knee joints. Her tongue was red with thick and yellowish tongue coating. Her pulse was deep and thready.

Diagnostic Differentiation:

TCM:

The patient suffered joint pains over her whole body for 13 years and being severe for 1 year, which belongs to the category of impediment pattern in TCM. When the patient was young, she did too much laborious work, which consumed too much essence and qi of her. The defense function of her body was decreasing. When sweating, the pores over the skin were open, and exogenous pathogenic factors invaded into the muscles, and then wandering to the bones and joints. The channels were blocked. When they blocked, the pains happened. The patient had been sick for 13 years. Exogenous pathogenic factors gradually changed into heat. Therefore, we could see purple ecchymosis over the skin of her four limbs and red tongue with thick and yellowish coating, which was caused by poor circulation of blood and blood stasis blocking the channels. Enlargement of the joints and inhibited bending and stretching were also caused by that. According to the above analysis, her condition should be impediment pattern, due to coldness and wind blocking the channel, accumulation of coldness changed into heat.

Western Medicine diagnosis:

1. Medical history: pains over the joints for 13 years.

2. Symptoms: painful joints, heat over the joints, deformation of the joints and inhibited bending and stretching.