Miss Kimbery, 32岁, 来自美国, 中医治疗

Name:Kimbery

 

Sex: Female

 

Age:  32

 

Marital status: Single

 

Occupation: Staff of Ford Car Company in USA 

 

Date of hospitalization: February 16, 2006.

 

Major complaints:

 Multiple atrophy and sclerosis on the skin of her both hands as well as stiff finger joints

 for 8 years.

 

Disease history:

    The skin of her both hands became tight without obvious reasons 8 years ago. The wrinkle vanished and her facial wrinkle also disappeared. There is waxen gloss on the surface of skin and the skin can not be pinched by hand. Fixed expression. It’s difficult for her to open and close the mouth. Tight feeling of her chest. She once took treatment in her local hospital, and took hormone medicine orally, but without obvious effects. Now we find her skin is atrophy and becoming thinner, it looks like parchment. Muscular dystrophy. Breathy difficulty. Stiffness and deformation of the finger joints. Restricted activities. Distention and fullness of the stomach duct. She is aversion to coldness. Cold limbs. Her both hands are stiff and deformed. Frequent cough. Phlegm is whitish and yellow. The sleep is OK. Appetite is not very good. The bowel movement and urination are normal. The tongue body is shortened and slightly reddish. Thin and whitish tongue coating. Deep and fine pulse. Last August she got first aid in the local hospital because of lung function failure. She also suffers from the lung fibrosis and pulmonary emphysema.

 

    Malnutrition. Normal development of her body. The state of mind is clear. Chronic disease sickly look. Fixed facial expression. The skin is cold and lack of elasticity. No bleeding spots or spider angioma, and no skin rash. We could not touch the lymph node under the two jaws and the surface of her whole body. The head is not deformed. No pressure pains and no phyma. The hair does not have gloss. No eyelid droop and no edema. No hyperemia and bleeding of the conjunctiva. The sclera is not yellow. The cornea is transparent. Normal size of the pupillae and well response to the reflection of light. The hearing ability is normal. No pressure pains of the nipples. The nasal cavity is smooth and no abnormal secretion. The oral cavity does not have the unusual odor. No cyanosis lips. The movement of the tongue body is not flexible. Atrophy tongue. The tongue coating is thin and whitish. No hyperemia of the throat. No swallow difficulty. The neck is soft. The trachea is placed in the middle. We can see the neck vein pulsates obviously. The chest is symmetrical. No pressure pains and no varicosity of the chest wall. The breast does not have sclerosis. The breath is shallow and quick. The rhythm is regular. The sound trembles are symmetrical. The pleura does not have the frictional feeling. The heart rate is 65 times per minute. The heart rhythm is uneven. There is no additional sound and the pericardium fricative. The abdomen is soft. No pressure pains and no rebound tenderness. No check-up of the liver, the spleen, the kidney, the anus and the external genital organs. Normal patellar jerk.

 

Individual history:

    No addiction of smoking and drinking. Menstrual period lasts 4-5 days per month and it is slightly reddish. She does not have history of tuberculosis and hepatitis or other infectious diseases. She has no experience of blood transfusion or allergy to medicine.  

No similar disease case in the family. Her parents are in good health.

 

Phsical examination:

Body temperature: 36 Celsius degree

Pulse: 20 times per minute

Heart rate: 60 times per minute

Blood pressure: 110/70 mmHg

 

Diagnosis:

   TCM : Numbness of the skin (The kidney Yang is insufficient, disharmony between yin and wei )

 Western Medicine: scleroderma

February 17, 2006. 

Both hands with belt-shaped atrophy and sclerosis as well as stiff

 finger joints for 8 years.

Take one dosage of herbal tea to warm and invigorates the kidney Yang, harmonize yin and wei and invigorate the lung qi. And use the herbal medicine to promote blood circulation and remove blood stasis and warm vessel.

Last night the condition is stable and sleep is OK. Her appetite is unsatisfactory. The bowel movement and urination are normal. Tongue body is slightly reddish, the tongue coating is thin and whitish. Deep and fine pulse. The accompanied doctors are physician-in-charge Dr. Ming and Dr. Qiu. They approve my treatment plan with acupuncture and massage treatment.

 

Dr. Ming / Dr. Yang

 

 

February 18, 2006.

     Today the spirit is not very good. The stomach is uncomfortable. A little bit diarrhea. Therefore we adjust the formula to recuperate the spleen and the stomach.

Formula: agastache 6g   tangkuei 6g   amomum fruit 6g   etc.

 

Dr. Yang

 

 

February 19, 2006.

    Today the spirit and sleep are good. Poor appetite and no desire for food. The tongue body is slightly whitish. Thin and whitish tongue coating. The pulse is fine.

Formula:  cinnamom twig 10g  carthamus flower 10g  millettia root and stem 30g etc.

 

Dr. Yang

 

 

February 20, 2006.

    Today the spirit is unsatisfactory. Distending pains of the stomach. She desires to vomit after eating. Tongue body is slightly reddish. The tongue coating is thin and white. Fine and rapid pulse. Headache and running nose.

Formula: bupleurum root 6g  ovate atractylodes root  10g  Poria 10g etc.

 

 

                                                                                     Dr. Yang

 

 

February 21, 2006.

     Today she feels good. Stomach distention disappeared. The appetite is better than before. Facial skin is not so tight. Tongue body is slightly reddish. The tongue coating is thin and whitish. The pulse is fine and rapid and deep. The bowel movement and urination are normal.

Formula: Poria 10g  codonopsis root 10g  salvia root 10g etc.

 

 

 

Dr. Yang

 

     February 22, 2006. Today she feels good. After several days acupuncture and massage treatment together with the help of the external use medicine treatment, the facial skin is softer than before. The spirit is good. She went to sleep at 3 o'clock in the early morning. Stomach distention disappeared. No diarrhea. Tongue body is slightly reddish. The tongue coating is thin and whitish. The pulse is deep, fine and rapid. The bowel movement and urination are normal.  Dr. Yang  February 23, 2006.  The facial expression gets obvious improvement. The limbs muscle relaxes. The spirit is good. The distention of the stomach vanished. The tongue can elongate longer than before. The tongue coat is thin and white. Saliva is few. The pulse is deep, thin and rapid. The feces and urination are normal.Formula:  Poria 10g  codonopsis root 10g  salvia root 10g etc. Dr. Yang

 

 

    February 25, 2006. Today she feels good. The facial skin is more relaxed than before. The wrinkle appears while smiling. No stomach distention. The finger joints can move more flexibly. The damaged skin is not as sunken as before. The mouth can open for approximately one and a half finger wide. Tongue body is slightly reddish. The tongue coating is thin and white with spots. The pulse is fine, rapid and powerful. The appetite is good. The bowel movement and urination are normal. The sleep is good.Formula: Poria 10g  codonopsis root 10g  salvia root 10g etc.

 

Dr. Yang

 

 

March 1, 2006.  

    The facial skin is more softer than before. The wrinkle appeared when she smiles. The finger joints can move more flexibly and not so stiff. Lower limb is a little bit swollen. Tongue body is slightly reddish. The tongue coating is thin and whitish with spots. The pulse is fine, rapid and powerful. Good appetite and sleep. Bowel movement and urination are normal.

Formula: Poria 10g  codonopsis root 10g  salvia root 10g etc.

 

Dr. Yang

 

March 4, 2006

.   She feels discomfort of the stomach. Stomach distention. Burp. Stiffness of the neck. The stiffness of the hand skin is obviously relaxed and softer. We can see the wrinkle after pressing her skin. When she smiles the face has the wrinkle as well. The bowel movement and urination are normal. The sleep is good. Tongue is slightly whitish. The tongue coating is thin and whitish with spots. The pulse is fine and stringy-like.Formula: Poria 10g  tangkuei10g  peach kernel 10g etc.

 

 

Dr. Yang

 

March 7, 2006.

    She doesn’t feel neck stiffness today. After pressing her skin, we can see the wrinkle. We can also see the dimple when she smiles. The bowel movement and urination are normal. The sleep is good. Tongue is slightly whitish. The tongue coating is thin and white. Fine and stringy-like pulse.Formula: Poria 10g  tangkuei10g  peach kernel 10g etc.


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