Brief Summary: On August 21, 2013, Mr. Yang Qiusheng, from the countryside near our hospital, who had been suffering repeated joints pains over his four limbs for 8 years, was hospitalized in our hospital. He used to be hospitalized in our hospital in March for severe pains over his knee joints. He achieved great improvement after 2 weeks TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization

Name: Yang Qiusheng                           Sex: Male

Age: 61                                                  Marital Status: Married

Nationality: China                                 Date of Admission: August 21, 2013

Companion: Alone

First Medical Record

Date: April 21, 2013                                Time: 12:00 a.m.

This 61-year-old man had been suffering repeated joints pains over his four limbs for 8 years. He was hospitalized in our hospital as a patient with rheumatic arthritis for TCM treatment at 12:00 a.m. on August 21, 2013.

Essential for Diagnosis:

1. The patient had been suffering repeated pains over his joints of four limbs for 8 years, and became severe. He could not go for work at least for 4 years. He denied any trauma. He had no allergy history of any medicine or foods.

2. When Mr. Yang came to our hospital, he suffered swelling pains over the joints of his four limbs. The joints have been badly deformed. He could not go for work. He has difficulty in walking. There was obvious edema over his lower limbs and the lower back part. He suffered headache occasionally, sometimes right side, and sometimes left side. He did not feel palpitations or chest depression. Sleep was good. Appetite was normal. He also suffered tinnitus and deafness. Urination was not normal, while bowel movement was normal.

3. T: 37C   R: 20 times/minute    P: 64times/minute   BP: 128/66mmHg

4. The patient had normal spiritual activity and chronic painful and dark facial expression. There was no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. His neck was soft with no resistance to stiffness. His chest was symmetrical. Rhythm of his heart was 64 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. His abdomen was soft with no pressing pains and rebound tenderness. There was no sign of deformity over his spine and four limbs. There were obvious pressing pains over his shoulder blades and both sides of his spinal column. There were no obvious pressing pains over his back. There was obvious edema over his lower limbs. Other test results were normal. His tongue was dark red, with thick and yellowish tongue coating. His pulse was deep, wiry and unsmooth.

Diagnostic Differentiation:

TCM:

The patient was an old man. The patient had been suffering pains over the joints of his limbs. Because of prompt treatment, his condition became severe day by day. In recent four years, he suffered severe pains over his shoulder joints and the joints of his lower limbs. The joints of his four limbs became swelling gradually and he suffered functional disorder. He could not go for work. He felt headache, dizziness and tinnitus. The long course of his disease caused deficiency of his kidney essence, qi and blood. The cold and dampness invaded into his limbs and bones, causing the qi and blood stagnated over the bones, which led deformation of the joints. According to the above analysis, his condition should be deficiency of Liver and Kidneys, cold and dampness invading into the bones.

Western Medicine diagnosis:

1. Repeated swelling pains over the joints of his limbs for 8 years.

2. Symptoms: Pains over shoulder blades and joints of the shoulders. Difficulty to lift his arms. Pains and edema over his lower limbs. Limitation to walk and could not go to work. Suffering headache, dizziness, tinnitus and unsmooth urination.