Brief
Summary:
Mr. Wallace, from USA,
had been suffering from pains over his back and legs as well
as edema over his lower legs for one and half years. He was
hospitalized in our hospital on May 28, 2011 for TCM treatment.
He achieved great improvement in his condition after nearly one
month TCM treatment with the help of herbal tea, acupuncture,
massage etc.
Record
of Hospitalization
Name:
Wallace Sex: Male
Age:
68 Marital
Status: Married
Nationality:
American Date of Admission: May 28,
2011
Companion:
Alone
First Medical Record
Date:
May. 28, 2011 Time:
14:00 pm
This 68-year-old
gentleman had been suffering from pains
over his back and legs as well as edema over his lower legs for
one and half years. The patient was hospitalized in our hospital
for TCM treatment on May 28, 2011.
Essential for Diagnosis:
1. The patient had been
suffering from pains and numbness over his back and legs as well
as edema over his lower legs for one and half years.
2. One and half years
ago, the patient was attacked by rachitis, and after the
treatment of surgery, he felt numb over his right face and both
upper limbs, and at the same time, he had binocular diplopia,
pains and numbness over his back and leg as well as edema over
his both lower limbs. After taking treatment in his local
hospital, numb feeling over his face and upper limbs, and
binocular diplopia disappeared. Right now, he still suffered
pains over his back and legs, and edema over his lower leg,
especially over his left leg. He had walking problem with bad
balance sensation. He also had chest depression, dizziness and
headache. He sometimes suffered abdominal distension and burning
pains over his stomach. Hearing of his both ears was going down
and he needed to wear hearing-aids. He was easy to be tired and
felt very weak over his whole general body. He felt dryness in
his mouth with no bitterness, bad breath in his mouth. Color of
his urine was slightly yellow and the volume was normal. Stool
was brown but unshaped. Sleep was not good, but appetite was
normal.
3. T: 36.2＜C R: 20
times/minute P: 62 times/minute BP: 125/80 mmHg
5. There were many red
nevi and black wine spots in different sizes over his body,
especially over his abdominal and chest parts. There was a 10cm
surgery scar over his lumbar. He felt numb and painful over his
buttocks. Several pressing-pain points existed over his lower
legs, especially the insides. Both lower limbs were swelling.
Telangiectasis and spider angioma were seen in his legs. He
walked under the help of walkers. His tongue was pale with thin
and white coating. The pulse was wiry and thready.
Diagnostic Basis and
Differentiation:
TCM:
The patient suffered from pains over his lumbar and leg, and
pains and numbness over his buttocks. There were pressing pains
over his lower limbs. Telangiectasis and spider angioma were
evidently seen in his legs. Therefore, his condition could be
diagnosed as Numbness syndrome and edema. Numbness syndrome
should be differentiated with atrophy syndrome. Both syndromes
show dyskinesia of the limbs, but the atrophy syndrome mainly
manifests muscle atrophy and uselessness of the muscles. Edema
should be differentiated with distension. Distension shows that
the abdomen is swelling like a drum and the skin shows
ochrodermia. Veins over the abdomen pop out. Therefore, it is
easy to differentiate them.
First Diagnosis:
TCM:
1. Numbness syndrome
2.
Edema
Western Medicine:
Spondylitis
postoperative
Treatment strategy and
nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade
Å
care.
3. Common diet.
5. TCM strategy:
to promote the circulation of qi and remove blood
stagnation, as well as to disinhibit water and disperse
swelling.
6. Herbal tea: one
dosage a day and drink twice.
7.
Acupuncture and massage: once a day.
Date:
May. 29, 2011 Time:
10:00 pm
Dr. Ming paid a visit to
the patient this morning. The patient complained that one and
half years ago, the patient was attacked by rachitis, and after
the treatment of surgery, he felt numb over his right face and
both upper limbs, and at the same time, he had binocular
diplopia, pains and numbness over his back and leg as well as
edema over his both lower limbs. After taking treatment in his
local hospital, numb feeling over his face and upper limbs, and
binocular diplopia disappeared. Right now, he still suffered
pains over his back and legs, and edema over his lower leg,
especially over his left leg. He had walking problem with bad
balance sensation. He also had chest depression, dizziness and
headache. He sometimes suffered abdominal distension and burning
pains over his stomach. Hearing of his both ears was going down
and he needed to wear hearing-aids. He was easy to be tired and
felt very weak over his whole general body. He felt dryness in
his mouth with no bitterness bad breath in his mouth. Color of
his urine was slightly yellow and the volume was normal. Stool
was brown but unshaped. Sleep was not good, but appetite was
normal. The tongue was pale with thin and white tongue coating.
Dr. Ming thought from the principle of TCM that his condition
should be Numbness syndrome and edema, which was due to qi
stasis and blood stagnation as well as stasis blocking the water
circulation. Therefore, the treatment should be to promote the
circulation of qi and remove stagnation as well as to disinhibit
the water and disperse swelling.
Date:
May. 30, 2011 Time:
10:00 pm
The patient said she
slept for 7 running hours. Other conditions were the same as
above-mentioned.
Date:
May. 31, 2011 Time:
10:00 pm
The patient said sleep
was good. Pains and edema over his lower limbs were reduced a
little bit, and his lower limbs could feel the heat and
coldness.
Date:
June. 1, 2011
Time:
10:00 pm
The
patient said the pains, edema and numbness over his lower limbs
were evidently better, while pains still existed on his back and
buttocks.
Date:
June 4, 2011 Time:
10:00 am
Edema over the patient¨s
lower limbs was improved greatly, and the limbs recovered
perception. The buttocks were still painful and numb.
Date: June 7,
2011 Time: 10:00
am
The patient complained
that the herbal tea was too bitter for him to swallow it.
Date: June10,
2011 Time: 10:00
am
Swelling over his lower
limbs was reduced a lot. There was no improvement in the pains
and numbness over his back.
Date: June13,
2011 Time: 10:00
am
The patient said his
back was still painful. He was about to vomit after supper last
night.
Date: June16,
2011 Time: 10:00
am
Today, the patient said
that pains and numb feeling over his back were reduced somewhat.
But feet were swelling during the night in recent two days and
in the second morning, swelling disappeared.
Date: June 20,
2011 Time: 10:00
am
Mr.
Wallace said the region of his back pains was nearly a circle
with the diameter of 15cm. Feet were swelling since 6 o¨clock in
the evening, and disappeared in the next morning. At present,
walking balance was better. His tongue was dark with yellowish
and greasy coating. His pulse was wiry.
Date:
June24, 2011 Time:
10:00 am
After
nearly one month TCM treatment in our hospital, now pains and
edema over his back and legs were improved. Swelling over his
two lower limbs was dispelled. Walking balance was much better.
He could control his walking speed and also he could walk
backwards by himself, even though he could not walk for a long
time. Now, he suffered no chest depression, dizziness, and
headache as well as spasm any more. The doctor advised him to
avoid wind and cold, take care of the diet and keep good mood.
In addition, he would take medicine back home continuing the
treatment. The patient also needed to keep exercise.
