Patient’s Name: Mr Jong, Age: 31
Date: 15 Jan 2020，First Consultation (Tele Conversation）
Main Problem：Leg edema and both ankles joint pain for two weeks.
The main issue is ankles joint pain and swollen leg for past two weeks. Joint pain is related to gout issue. Walk like limping. When walking for a long distance, he can easily get panting and breathe hardly.
Recently, he has lost his appetite, seldom feel hungry. No bloated stomach and always burping.
He always feels thirsty and drinks much water per day. Heavy perspiration especially the head has always been sweating heavily. He scared coldness and does not like hot temperature as well.No mouth ulcer but when brushing teeth, he gets bleeding easily.
He has no good sound sleep as easily wake up in the midnight, and dream a lot. He feels easily distracted by sound and light in the bedroom.As a consequent, he always feels tired the next day. Farting is smelly. Urinating is smooth and not smelly but frothy. He has a good bowel movement habit, sometimes the stool is sticky.
27-01-2020 Feedback by Mr. Jong :
After consumed the medicine, he started to observed some alleviation for the swollen leg. When he walked, the angle joint pain reduced.
30-01-2020 Feedback by Mr. Jong :
The medicine patching has helped to mitigate some water retention. The pain has slowly relieved.
08-02-2020 Feedback by Mr. Jong :
He has been kept exercising by walking, he sees it works as after walking for a long distance every day, it has improved the blood circulation and reduced the water retention.
Diagnosis：
Due to work stress, the patient has been working long hours in front of pc and lack of doing exercise. Eating plentiful in our meal and slowing digestive system causing the heat kept inside the body. Hence, he has always been thirsty and sweating heavily especially the head part. When the body is heaty, blood becomes heaty as well, influencing the blood circulation. Eventually causing severe inflammation and hence he got the gout pain at both the ankle joints. Due to less exercising, water circulation is slowing down too. The functionality of the lung has deteriorated and causing slower water circulation, the outcome is easily gets panting and hard breathing. In additional, the neck and shoulder has been always feeling stiff and causing him to feel headache and dizziness. Intestinal heat always caused smelly farting. Due to intaking more protein oriented food in the daily meal, it seems he got frothy urine, we excluded the weakening kidney functionality into considered factor. The patient also having some emotional feeling due to stress he faced during work or life causing him a light sleeper, dreaming a lot and easily wake up in the midnight and sensitive to sound and light in the bedroom.
Some tips for our daily life styles:
- Regular exercise for healthy maintenance and improving blood circulation so that strengthening the muscles and joints.
- Regular exercise for stimulating the brain to release endorphin which is the natural pain reliever and promote pleasure.
- During working hours, remember to drink more water so to improve water circulation and promote metabolism in the body.
- Improve air circulation interiorly and adjust the light into a soothing vibes to improve the sleeping quality.
- For heaty type of body, he has always likes the body to be cooling down. Always pay attention to avoid over attack by the “wind”, the coldness and the dampness.
- Balancing diet, no overtaking protein oriented food. Diet should take equal balance of sugar, carbohydrate and fats.
- For heaty type of body, they are suitable to take non-heaty food such as vegetables and fruits.
- Foster calmful mind and good communication with family and friends.
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