[Case study]One rheumatoid arthritis case

The patient, female, in her thirties, complained of joint pain for more than six months. At present, the main symptom is joint pain in the whole body. Since September last year(2021), the left knee joint had pain when pressed, going up and downstairs, and squatting. In January of this year, the pain shifted to the same spot on the left knee. At the same time, the pain in the finger joints of the left hand is slowly transferred to the same position of the right finger joints. Later, the inside of the wrist, right toe joint, and right heel started to pain. She also had pain in the mandible, and was unable to open the mouth, and could only open up to two fingers. The current state of pain is sometimes relieved and sometimes aggravated. Pain is moving among joints. The pain is located in the bone level, there is no tingling, no numbness, and a little pain in flexion and extension, but no obvious limitation. The rheumatoid factor test result was 21IU/ml (<14), and the Western medicine diagnosis was rheumatoid arthritis.

The patient is currently taking western medicine hepatitis B antiviral drugs and has gastrointestinal discomfort, poor spirit, dizziness, indigestion, loss of appetite and other symptoms.

Patients wake up in the morning with lower back discomfort. She felt aversion to cold, but not to wind. She has low blood pressure, her minimum heart rate can be 40bpm, and her low blood pressure is around 60-80mmHg. Heart palpitations and shortness of breath have occurred. Usually sweating a lot. The tongue colour is quite pale, the tongue coating is thin and white, and there is a blood deficiency sign. Due to the online diagnosis of patients, there is no pulse diagnosis information. This is the syndrome of ‘Bi’ in traditional Chinese medicine, and the traditional herbal formula was prescribed for two weeks.

The patient stopped taking the medicine because of the Covid-19 fever and cough in the middle, so it took about four or five weeks to finish all the two-week medicine. The patient reported that the mouth could be opened after a week, the pain has been significantly reduced, and not moved around. Another two weeks of medication continued to consolidate.

The patient has been taking medicine on and off because of the Covid, flu and work. Therefore, being able to control the current effect is very satisfying to her. From my clinical experience, the problem of rheumatoid arthritis, because of its deep location and many factors (including wind, cold, and dampness), needs some longer continuous treatment to be controlled to achieve no pain and long-term without recurrence. Especially, the improvement of the patient’s body energy condition is particularly important.