Name: Zeng Xiangfa                                                         Sex: Male

Age: 59                                                                             Marital Status: Married

Nationality: China                                                             Date of Admission: Apr. 26, 2015

Companion: Alone 

First Medical Record 

Date: April 26, 2015                                Time: 12:00 a.m. 

This 59-year-old man had been suffering from pains over his lumbar for five years. His condition became severe in this recent month. The patient was hospitalized in our hospital as a patient with Prolapse of Lumbar Intervertebral Disc for TCM treatment at 12:00 a.m. on April 26, 2015. 

Essential for Diagnosis: 

1. The patient had been suffering repeated pains over his lumbar, and companied by numbness over his left leg for more than ten years. His condition became severe in recent 7 days. There is no allergic history of any medicine or any food. 

2. When he came to our hospital, he suffered pains over his back, he could not bend towards. There were numbness and pains over his left leg. And the numbness radiated to his feet. He could not bend, squat and felt difficult to sit, stand and walk for a long time. The pains were related with the weather changes. Whenever the weather was getting cold, the pains got worse. Recently because of the weather changes, his condition became worse, it affected his laborious works and his sleeping. He also suffered occasional dizziness, chest oppression and headache. The urination and bowel movement were normal. 

4. T: 36.6°C   R: 20 times/minute    P: 80 times/minute   BP: 140/70mmHg 

5. 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. There were pressing pains over his shoulders and back. Facial features were normal without masses. His trachea was symmetrical. 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 80 times per minute. Heart rate was regular with no murmurs. His abdomen was soft with no pressing pains and rebound tenderness. There was no sign of deformity over his spine. There were obvious pressing pains over L4 and L5. When the doctor press his Huantiao Poit, the numbness radiated to his left leg and toes. Elevation test of straight left leg (+), Bragard Test (+). His tongue was dark red with white and thick tongue coatings. His pulse was string, deep and weak.

Diagnostic Differentiation:

TCM: Lumbargo

Western Medicine diagnosis:

1. Prolapse of Lumbar Intervertebral Disc

2. Original Hypertesion

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ 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. 27, 2015                                            Time: 10:00 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 toes. He felt difficult to sit, stand and walk for a long time. It affected his laborious works and his sleeping. Whenever the weather was getting cold, the pains got worse. There were obvious pressing pains over L4 and L5. When the doctor press his Huantiao Poit, the numbness radiated to his left leg and toes. Elevation test of straight left leg (+), Bragard Test (+).His tongue was dark red with white and thick tongue coatings. His pulse was string, deep and weak. His appetite and sleeping were affected by the pains and numbness. The urination and bowel movement were normal.

Date: April 30, 2015                                            Time: 9:00 a.m.

The vital signs of the patient were stable. The patient said that after treatment, the pains over his lumbar slightly relieved. And the numbness obviously improved. He felt his leg was much stronger than before.  His sleeping and appetite were better. The pressing pains over his lumbar relieved.  

Date: May 04, 2015                                            Time: 9:00 a.m.

The vital signs of the patient were stable. The patient said the lumbago obviously improved. And the numbness over his left leg also relieved slightly. But he still could not walk for long time. If he walked too far, there were pains and weakness over his lower limbs. His appetite and sleeping were normal. He still felt the pressing pains over his lumbar vertebra.

Date: May 08, 2015                                            Time: 9:00 a.m.

The patient was in good spirit status. The patient said the lumbago relieved, yet it could not bear much weight and power. And he still has the numbness over his left leg. Occasionally the numbness radiates to his toes. The walking was slightly flexible. The tongue coating was white and thin. The pulse was deep and string.