Mr. Omar described his wife's
improvement in Arabic
Please Check
Brief Summary:
On April 19, 2012, Fatima, from
Libya, who had been suffering skin impediment in traditional Chinese
medicine (TCM) or systemic sclerosis in the concept
of western medicine, accompanied by tightness, atrophy and ulcer over the
skin of her face, elbows and the parts below her knee joints for 19 years,
was hospitalized in our hospital. She achieved significant improvement after
74 days TCM treatment.
Record of Hospitalization
Name:
Fatima Sex: Female
Age:47
Marital Status: Married
Nationality:
Libyan
Date of Admission: Apr. 19, 2012
Companion:
Her Husband
First Medical Record
Date:
Apr. 19, 2012 Time: 11:00 am
This 47-year-old lady
had been suffering from skin impediment, accompanied
by tightness, atrophy and ulcer over the skin of her face, elbows and the
parts below her knee joints for 19 years. The patient was hospitalized in
our hospital for TCM treatment at 00:00 am on April 19, 2012.
Essential for Diagnosis:
1. The patient had been suffering
from tightness, atrophy and ulcer over the skin of her face, elbows and the
parts below her knee joints for 19 years. She had entered menopause for 18
years.
2. When the patient came to our
hospital, skins over her face, elbows and regions below knee joints were
tight. Fingers and toes suffered ulcers. Hands felt cold. The four limbs
were stiff and heavy. She felt feverishness in palms and soles sometimes.
She could walk for 1 km, but if walked for a long time, she felt burning and
pricking pains over her feet. She had slightly headache. She had occasional
dizziness and tinnitus. She suffered vision loss. Her eyes were dry and
itchy. She could not open her mouth fully. She felt dryness and slight
bitterness in her mouth. She liked drinking warm water. Her throat was dry
without phlegm. Swallowing was not very smooth. Her appetite was good. She
had no gastric pains or abdominal distension. Bowel movement was once in one
or two days. Urine sometimes was clear, while sometimes was yellowish.
3. T: 36.5¡ãC R: 20 times/minute
P: 71 times/minute BP: 120/70mmHg
4. The patient was alert and
cooperative and had a positive body position. She grew normally with
emaciation and old face. Her scalp became thin and her hair became sparse.
Her facial complexion was dark without any luster. Her face was full of dark
red spots, and when pressing these spots, the color faded. Her skin was
stiff and atrophy. Skins over her forehead and tips were shrinking. Both
eyes were depressed and her nose wing was thin and sharp. Auricle became
small with stiff skin and low elasticity. She could not open her mouth
fully. She felt tired to extend her tongue. She suffered loss of teeth and
wore
dentures.
Skins over her neck, upper arms, legs and buttocks were rough. Pigmentation
was seen from the elbow tips to the wrists and over the knees. The joints
were shrinking with dark brown color. Joints of the fingers and toes were
stiff and deformed and shortened. Finger-tip and toe-tip bones were
of intercept shape. There were ulcers over her hands and feet. Reflection of
her knee tendons was reduced. Skins over her front chest, her back, and
joints of her wrists and ankles were shrinking. Pigment loss was seen over
her hand back and finger joints; and skins over these pigment loss region
were white. Her tongue was red with yellowish coating. Her pulse was
thready, wiry but rapid.
Diagnostic Basis:
TCM:
Skin over the patient¡¯s face and elbows and below the knees became hard and
atrophic, accompanied with ulcers for 19 years. Skin over her whole general
body was rough. These symptoms belong to the skin impediment in TCM. She
suffered deficiency of the liver and kidneys since she entered the menopause
period, which caused that the liver-blood could not nourish the skin and
muscle. Kidney deficiency led to tinnitus. Due to long duration of the
disease, it caused blood stasis and abnormal circulation of blood and qi;
therefore, ulcer, color mottles, burning pains and pricking pains were seen.
So, her conditions could be diagnosed as skin impediment, due to the
deficiency of the liver and kidneys and the stagnation of blood and blockage
of channels.
Western Medicine:
Skin over the patient¡¯s face and elbows and below the knees became hard and
atrophic, accompanied with ulcers for 19 years. Skin over her whole general
body was rough, with color mottles in some parts of the body and
pigmentation. The joints of her fingers and toes were stiff, deformed and
shortened. She felt limitation on opening her mouth. Her condition had been
diagnosed as systemic scleroderma at her local hospital.
First Diagnosis:
TCM: Skin impediment.
Symptom identification:
the deficiency of liver and kidneys as well as the stagnation of blood
and blockage of channels.
Western medicine diagnosis: Systemic
sclerosis.
Treatment strategy and nursing:
1. Routine care of traditional
Chinese internal medicine.
2. Grade
¢ò
care.
3. Common diet.
4. Pathogenesis: the deficiency of
the liver and kidneys and the stagnation of blood and blockage of channels.
5. TCM strategy:
nourishing the liver and kidneys, promoting blood circulation and
removing 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.
Date: Apr. 20,
2012 Time: 9:00 am
Doctor Zhu Ming paid a visit to the
patient. The patient complained that skin over her face, elbows and regions
below knee joints was tight. Fingers and toes suffered ulcer. Hands felt
cold. The four limbs were stiff and heavy. She felt feverishness in palms
and soles sometimes. She could walk for 1 km. But if walked for a long time,
she felt burning and pricking pains over her feet. She had slightly
headache. She had occasional dizziness and tinnitus. She suffered vision
loss. Her eyes were dry and itchy. She could not open her mouth fully. She
felt dryness and slight bitterness in her mouth. She liked drinking warm
water. Her throat was dry without phlegm. Swallowing was not very
smooth. Skin over her forehead and tips was shrinking. Both eyes were
depressed and her nose wing was thin and sharp. Auricle became small with
stiff skin and low elasticity. She could not open her mouth fully. She felt
tired to extend her tongue. She suffered loss of teeth and wore
dentures. Finger-tip and toe-tip bones were
of intercept shape. There were ulcers over her hands and feet. Her tongue
was red with yellowish coating. Her pulse was thready, wiry but rapid.
From the view of TCM, Zhu Ming, the
doctor thought that the case of the patient could be diagnosed as skin
impediment, due to the deficiency of liver and kidneys as well as the
stagnation of blood and blockage of channels.
Date: Apr. 21,
2012 Time: 9:00 am
Examination feedback: WBC 3.8*109/L,
Urine-R (-), Stool-R (-), Blood-LF (-), SPS (-), BS (-), HIV (-); ECG: sinus
rhythm, P-R interphase shortened. The functions of the liver, gallbladder,
spleen, pancreas and kidneys were normal. Uterine adnexas were not clear.
Date: Apr. 22,
2012 Time: 9:00 am
The patient
said there was no obvious
improvement in her conditions. Continued the previous prescription.
Date: Apr. 25,
2012 Time: 9:00 am
The patient felt more flexibility
over her ankle joints. Pains over her feet were reduced somewhat.
Date: Apr. 28,
2012 Time: 9:00 am
The patient said she felt her body
was more relaxed than before. At the same time, she could walk longer than
before.
Date: May 3,
2012 Time: 9:00 am
Ms. Fatima said skins over her whole
body were softer than before and her ankle joints were flexible than before.
There was no heat over her palms and soles. Pains over her ulcer were
reduced somewhat. Her tongue was red with yellowish coating. Her pulse was
thready and wiry but rapid.
Date: May 7,
2012 Time: 9:00 am
The patient¡¯s condition was stable
without any special changes. Her tongue was pale with yellowish coating. Her
pulse was thready and wiry but rapid.
Date: May 12,
2012 Time: 9:00 am
The patient said her condition was
better. Skins over her whole body were softer. Pains over the ulcer regions
of her limbs end were reduced. Her tongue was slightly red with yellowish
coating. Her pulse was thready and rapid.
Date: May 17,
2012 Time: 9:00 am
The patient said her conditions were
better. Wrists joints were much more flexible than before. Her tongue was
slightly white, with teeth marks on the tongue sides. The tongue coating was
yellow and greasy in the middle of the tongue.
Date: May 21,
2012 Time: 9:00 am
The patient said there were pains
over the ulcer regions of her soles. Other symptoms were just like before.
Her tongue was slightly white with yellowish and greasy coating. Her pulse
was thready and wiry.
Date: May 24,
2012 Time: 9:00 am
Condition of the patient was stable.
Pains over her ulcer regions were reduced.
Date: May 28,
2012 Time: 9:00 am
The patient complained that there
still were pains over the ulcer region of her soles. Joints movement of her
ankles and wrists were more flexible. Her tongue was white with yellowish
tongue coating. Her pulse was thready and wiry.
Date: Jun. 1,
2012 Time: 9:00 am
The patient suffered burning feeling
over her stomach last night. Other conditions were just like before.
Date: Jun. 4,
2012 Time: 9:00 am
The patient said that there were no
burning feelings over her stomach. Pains over the ulcer regions of her soles
were better. Her tongue was slightly red with yellowish coating. Her pulse
was thready and wiry.
Date: Jun. 7, 2012
Time: 9:00 am
The patient said her condition was
better. The ulcer surface had been scabby. Skins over her whole general body
were softer than before. Black brown parts on her front chest, elbows and
knees became lighter. Her tongue was slightly red with yellowish coating.
Her pulse was thready and wiry.
Date: Jun. 10, 2012
Time: 9:00 am
The
patient said her condition was the same as days before.
Date: Jun. 15,
2012 Time: 9:00 am
The patient said her condition was
the same as days before. She had no difficulty in swallowing. There was no
uncomfortable feeling over her throat or burning feeling over her stomach.
Her tongue was pale with yellowish tongue coating. Her pulse was wiry and
thready.
Date: Jun. 18,
2012 Time: 9:00 am
The patient said her condition was
the same as days before. There was no special improvement in her condition.
Her tongue was pale with yellowish tongue coating. Her pulse was wiry and
thready.
Date: Jun. 21,
2012 Time: 9:00 am
The patient said skins over her
whole general body were softer than before. Pains also were reduced a lot.
Her tongue was pale with yellowish tongue. Her pulse was wiry and thready.
Date: Jun. 24,
2012 Time: 9:00 am
Condition of the patient was stable.
Her tongue was pale with yellowish tongue coating. Her pulse was wiry and
thready. Continued the previous treatment prescription.
Date: Jun. 27,
2012 Time: 9:00 am
The patient complained of slight
edema over her feet back. Other symptoms were the same as days before. Her
tongue was pale with yellowish tongue coating. Her pulse was wiry and
thready.
Date: Jul. 1,
2012 Time: 9:00 am
Fatima said edema over her feet back
was better. Skin over her whole body was softer than before. Pains over her
ulcer regions were reduced evidently. She no longer felt cold over her hands
and feet. No more abnormal heat over her palms and soles. Stiffness of the
joints of her four limbs changed better. Dizziness and tinnitus were gone.
Eyes were no longer dry and itchy. She no longer felt bitter in her mouth
and dry in her throat. Swallowing was normal. Facial complexion was much
lustrous than before. The color of pigmentation region was fade out
somewhat. Joints of her fingers and toes were flexible than before. For the
expiration of visa, Ms. Fatima asked to leave our hospital today.
Doctor¡¯s advice
after leaving hospital:
1. Avoid wind-cold, maintain good
moods, and take care of the diet.
2. Take herbal medicine back for continuing treatment.
