Brief
Summary:
On
April 15, 2015, Mr. Shi Xianzhou, from Longjing village of Zhongfang County,
who had been suffering repeated pains over his lumbar, companied by numbness
over his left leg for more than ten years, and being severe for 3 months. He was
hospitalized in our hospital. He achieved great improvement only after 16 days
TCM treatment with the help of acupuncture, herbal tea and tuina in our
hospital.
Record of
Hospitalization
Name:
Shi Xianzhou Sex: Male
Age: 60
Marital Status: Married
Nationality: China
Date
of Admission: Apr.
15, 2015
Companion: Alone
First Medical Record
Date: April
15, 2015 Time: 10:30
a.m.
This 60-year-old man had
been suffering from pains over his lumbar for ten years, companied by numbness
over his left leg for more than ten years, and being severe for 3 months. The
patient was hospitalized in our hospital as a patient with Prolapse of Lumbar
Intervertebral Disc for TCM treatment at 10:30 a.m. on
April 15, 2015.
Essential for Diagnosis:
1. The patient had been suffering repeated pains over his lumbar,
and accompanied by numbness over his left leg for more than ten years. His
condition became severe in recent 3 months. There was the history of lumbar
sprain and orchitis surgery. There is no history of allergic any medicine or
any food.
2. When he came to our hospital, he suffered pains over his lumbar and his left
skeletons spine joint, and accompanied by numbness over his left leg. And the
numbness radiated to his feet. In recent 3 months, his condition was getting
worse. He can¨t walk, stand and sit for a long time. When he turned over his
body in bed, the pains were severe. He felt cold, while his skin was hot. He
also suffered occasional dizziness, yet without headache and tinnitus. Sometimes
he had sweating. His appetite and sleeping were good. The urination and bowel
movement were normal.
3. T: 36.8＜C R: 20
times/minute P: 66 times/minute BP: 140/70mmHg
4. The patient grew
normally with standard body shape. He was alert and cooperative. He had chronic
sick facial complexion. He was in compulsive position. There was no sign
of yellow sclera or yellowish skin and also no enlargement on the superficial
lymph node of his whole body. His neck was soft without resistance. His trachea
was symmetrical. Facial features were normal with masses. There was no
enlargement over his thyroid. The jugular vein was of no engorgement. His chest
was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi.
Rhythm of his heart was 66 times per minute. His abdomen was soft with no
pressing pains and rebound tenderness. There was no obvious swelling, yet with
slight pressing pains. There was no sign of derformity over his spine. There was
obvious pressing pains aroung his lumber vertebra. Elevation test of straight
left leg (+), Bragard Test (+). The meningeal irritation sign was negative.
There were no pathological reflections, but the physiological reflections
existed. His tongue was dark red with yellow tongue coatings. His pulse was
string, deep and powerful.
Diagnostic
Differentiation:
TCM:
Lumbargo
Western Medicine
diagnosis:
Prolapse of Lumbar
Intervertebral Disc
Treatment strategy and
nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade Å care,
Common diet, monitoring the blood pressure, once a day.
3.Sleep on a hard bed.
Avoid
wind-cold, regular daily life, have a good mood and take care of diet.
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
Date: Apr. 16,
2015 Time: 9:00 a.m.
Dr. Zhu Ming,
doctor-in-charge, paid a visit to the patient this morning. The patient
complained that he had suffered from the pains over his lumbar because of lumbar
sprain ten years ago. He did not care this problem. He just put some plasters
upon his lumbar, and the symptoms relieved at that moment. Later the lumbago
repeated, and the condition was getting worse day by day. He could not bend and
even could not turn over his body. Recent years, he felt the numbness of his
left leg, and it radiated to the sole. Sometimes there were sore and distent
pains around hip joints. He felt difficult to sit, stand and walk for a long
time. He felt cold, while his skin was hot. He could not turn over his body in
bed. Sometimes he had dizziness and headache. It was not related with the
weather changes. There was no tinnitus. His appetite was good, the urination and
bowel movement were normal. Body checked, there were obvious pressing pains over
his lumbar. Elevation test of straight left leg (+),Bragard Test (+).His tongue
was dark red with yellow tongue coatings. His pulse was string, deep and
powerful.
Date: April 19,
2015 Time: 9:00 a.m.
The patient said that
after treatment, the pains over his lumbar slightly relieved. And the numbness
also improved. It was better for bending and stretching his waist. And it was
much easier for walking. His sleeping and appetite were good. The urination and
bowel movement were normal. The tongue coating was yellow. The pulse was string,
slow, deep and powerful.
Date: April 23,
2015 Time: 9:00 a.m.
The vital signs of the
patient were stable. The patient said the lumbago obviously improved. And the
pains over his knees relieved. The pressing pains around his lumbar vertebra
obviously relieved. The tongue coating was white, the pulse was deep and string.
Date: April 27,
2015 Time: 9:00 a.m.
The patient was in good
spirit status. The patient said the lumbago improved greatly, yet he still could
not walk as normal. When walking, his body created a little bit of tilt. The
pains over his knee-joints disappeared. Elevation test of straight left leg
still was positive. The tongue coating was white, the pulse was deep and string.
Date: May
01, 2015 Time: 9:00 a.m.
The vital
signs of the patient were stable. The lumbago improved greatly. He could bend
his waist freely. The function of bending and stretching his knees was normal.
The tongue coating was white, the pulse was deep, string and slow. The patient
decided to leave the hospital today. In order to consolidate the effect, the
patient took the herbal tea back.
