Brief Summary: On July 30, 2013, Ms. Zhou, 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 18 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization

Name: Zhou                                         Sex: Female

Age: 56                                                Marital Status: Married

Nationality: China                                Date of Admission: July 30, 2013

Companion: Alone

First Medical Record

Date: July 30, 2013                                Time: 09:00 a.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 09:00 a.m. on July 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 did not have 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-prickling. 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 was hyperemia sign over her eyes. The patient had been hospitalized in our hospital for TCM treatment for 17 days. At that time, her conditions were more severe, such symptoms as skin ecchymosis with purple color over the skin of her limbs. Her conditions were improved a lot. There were no more purple spots over her skin. And the color of the skin was closing normal condition. She felt dryness and bitterness of her mouth. She was afraid of coldness. 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: 100/60 mmHg

4. The patient had normal spiritual activity and painful facial expression. There were no sign of yellow sclera or yellowish skin. There was slight hyperemia sign over her eyes. There was skin ecchymosis with purple color over the skin of her limbs, but it was very light. 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 pains happened, it liked needle-prickling. 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 was hyperemia sign over her eyes. After the 17 days TCM treatment two month ago, her condition was improved a lot. There used be the symptoms of large scale of skin bleeding and severe weakness symptom, but right now, those symptoms were almost gone. The patient was old, and the balance of yin and yang of her body was changed, which weakened the function of zang and fu organs. Exogenous pathogenic factors invaded the body and gradually changed into heat, which blocked the channels and joints. When the channels blocked, pains happened. 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.