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Name: Xue.
Sex: Female.
Age: 51 years.
0ccupation: A peasant.
Chief Complaint: Malformed fingers and pain for 2 years.
History of Present Illness: Two years ago, the patient got a pain in her fingers of both hands without obvious causes. It' s a constant prinkling like pain, accompanied with morning rigidity. After treatment of taking chinese herbs and Western medicine in the local hospital, there was no curative effect on her. Furthermore, the interphalangeal articulations of hands became red and swollen, and then got malformed. At last, they became spindle-like malformation, the fingers of both hands couldn't crook back. In the past 2 years, she got an insufferable pain so that she couldn't sleep well. Then she came our hospital for treatment on January 23, 1996. After the illness came on, she kept her spirit normal. In addition her stool was loose and formless, her urine was white and abundant. There wasn't other complaint.
Physical Examination: The patient was conscious with a normal general condition. The pulse was thready and uneven, the tongue was pale and teeth-printed with a thick layer of watery fur. The interphalangeal articulations of both hands were all malformed, they looked spindle-like, but they weren't red and swollen, there was tenderness in them which caused they could not be palpated. There was not other abnormal sign.
Diagnosis: Rheumatoid Arthritis.
Differentiation: This disease, in TCM, belongs to the category of "WangBi" (severe osteoarthritis). It's caused by wind-cold and dampness evils, which got into the finger bones and stayed there permanently. As a result of it, the finger joints became spindle-like and malformed. In addition, the pulse and the tongue reflected there were deficiency of spleen-qi and retention of phlegm-dampness evils. As for the sharp pain in the finger joints, it was caused by the accumulation of cold-dampness evils.
Therapeutic Principle: Strengthening spleen to percolate dampness, strike blood stasis and eliminating phlegm, dredging the obstructed meridinan, invigorating qi and nourishing blood, activating blood to resolve stasis.
Recipe :
YiYiRen,Coix Seed
BaiJieZi,White Mustard Seed
ZhiChuanWu, Prepared Sichuan Aconite Root
ZhiHuangQi, Moxa-prepared Milkvetch Root
DangGui,Chinese Angelica Root
ChuanXiong,Chuanxiong Rhizome
ShuDiHuang,Prepared Rehmannia Root
ZhiCaoWu, Prepared Wild Aconite Root
ChuanShanJia, Pangolin Scale
WuShaoShe, Black-tail Snake
QiangLang, Dung Beetle
WeiLingXian,Clematis Root
GuiZhi,Cinnamon Twig
QiangHuo,Notopterygium Root
GanCao,Liquorice Root
All the above drugs were to be decocted in water for oral taking. 5 doses were prescribed, cold food was forbidden during the treatment.
Effect Observation: After 5 days' treatment, the pain in the finger joints was relieved greatly, the fingers of both hands could crook back. Then she was told to continue taking 5 doses of the above prescription. After taking the decoction, the pain disappeared, the movement of her fingers became freely. After half a year' s follow-up, the illness didn' t recur again. Then it' s ending.
