Name: Ms. Pan Juying                                          Sex: Female

Age: 64                                                                Marital Status: Married

Nationality: China                                                Date of Admission: March 22, 2015

Companion: Alone

First Medical Record

Date: March 22, 2015                                    Time: 12:00 a.m.

This 64-year-old woman had been suffering from repeated pains over shoulder joints for more than ten years, and being severe for half a month. The patient was hospitalized in our hospital for TCM treatment at 12:00 a.m. on March 22, 2015.

Essential for Diagnosis:

1. The patient had been suffering from repeated pains over shoulder joints for more than ten years, and being severe for half month. She suffered from lumbago for more than ten years as well. She had lumbar sprain history in the year of 1979. She had no allergy history of any medicine or any food.

2. When the patient came to our hospital, she suffered joint-pains over her shoulders, and she could not lift up her arms. It was limited to stretch her arms towards her back. Sometimes she felt numb over her upper limbs, and her fingers were chilly. There was numbness and pains over her right lower limb. She could not walk or sit for a long time. If sitting for a long time, she felt tired. She felt sore over her knee-joints, while it does not relate with the weather changes. Appetite was good. Sleep was normal. Urination and bowel movement were normal.

3. T: 36.8°C     R: 18 times/minute    P: 66 times/minute     BP: 130/70mmHg

4. The patient grew normally. He was alert and cooperative. He had chronic sick facial complexion. There was  no sign of yellow sclera or yellowish skin. There was no enlargement on the superficial lymph node of her whole body. Her neck was soft without resistance. She could turn her neck flexibly. There were obvious pains around her shoulder joints and elbow joints. The movement of lifting her upper limbs was slightly limted. It was better to stretch her left arm towards her back than to stretch her right arm. Her windpipe appearance was good and in the center. There was no distention of jugular vein. There was no enlargement on her thyroid gland. Rhythm of her heart was 66 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. We did not hear any pathologic sound. Her abdomen was soft with no pressing pains, rebound tenderness and enclosed mass. There were slight pressing pains over her S4, S5. Elevation test of straight right leg (+), Bragard Test (+). No pathological neuropathic positive. Her tongue was slightly red. Her tongue coating was thin and white. Her pulse was deep and unsmooth.

Diagnostic Differentiation:

TCM: 1. Shoulder Impediment

            2. Lumbargo

Western Medicine diagnosis:

1 Shoulder periathritis

2. Prolapse of Lumbar Intervertebral Disc

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ care, Common diet.

3. Blood pressure monitoring, once a day.

4. Completed the related examination, three routine inspection, the function of the kidneys and the liver, blood fat, blood sugar, anti-O, RF and IMX..

5. Herbal tea: one dosage a day and drink twice

6. Acupuncture and massage: once a day

7. Avoid wind-cold, regular daily life, have a good mood and take care of diet.

Date: Mar. 23, 2015                                            Time: 10:00 a.m.

Date: Mar. 27, 2015                                            Time: 09:00 a.m.

The vital signs of the patient were stable. The patient said that after treatment, pains over her shoulder joints slightly relieved. While she still could not lift her arms. There were obvious pains around her elbow joints. And there was no changes on her lumbago. Sometime she still had sensation of numbness over her lower limbs. Her appetite was good. Her sleeping was not good. Her urination and bowel movement were normal. There were obvious pains over her elbow joints, it was difficult to lift her arms. And there were obvious pains around her lumbar vertebra. Elevation test of straight right leg (+). Continue the same formula.

Date: Mar. 31, 2015                                            Time: 09:00 a.m.

The vital signs of the patient were stable. The patient said that pains over her shoulder joints and elbow joints obviously relieved. And the movement of lifting her upper limbs   was improved obviously. And her lumbago also improved obviously. And the sensation of numbness over her lower limbs was better. Her sleeping improved as well.

The patient said the pains over her shoulder joints improved obviously. And she could lift her arms flexibly. Yet she still had pressing pains around her elbow joints. The movement function of her lower limbs was normal. The pressing pains over her shoulder almost disappeared. Yet there were slight pressing pains around elbow joints and her S3, S4, S5.

Her tongue coating was white. Her pulse was deep and slow, it was much more powerful than before.    

Date: Apr. 04, 2015                                            Time: 09:00 a.m.

 The vital signs of the patient were stable. The patient said there were about 80% improvements on the pains of her shoulder joints. And the movement function of her upper limbs was almost normal. And the lumbago improved obviously. There were no pains over her back. Her appetite and sleeping were good, yet she still had cough with phlegm. The movement function of her lower limbs was normal.   

After seven days TCM treatment with the help of herbal tea, acupuncture and massage, the patient’s condition got great progress. The patient decided to leave the hospital today. In order to consolidate the effect, the patient took the herbal tea back.

Doctor’s advice after leaving hospital: 

1. Avoid cold-wind. Keep good mood. Pay attention to diet.