Record of Hospitalization

Name: Pan Le                                                                                                                    Sex: Male

Age: 41                                                                                                                              Marital Status: Married

Nationality: China                                                                                                              Date of Admission: Jan. 22, 2013

Date: Jan. 22, 2013                               Time: 15:00 p.m.

This 41-year-old man had been suffering lumbar pains for 13 years, developed into numbness over her left lower limb for 6 days. The patient was hospitalized in our hospital for TCM treatment at 14:30 pm on January 22, 2013.

Essential for Diagnosis:

1. The patient had been suffering lumbar pains for 13 years, developed into numbness over her left lower limb for 6 days.

2. The patient complained that he suffered severe lumbar pains after labor work 13 years ago. At that time, he went to the western hospital for treatment, and then he got recovered with no more pains. 2 years ago, due to overexertion of his lumbar, pains over his lumbar were much severer, with numbness and pains over his left lower limb. He went for the help of western medicine, and pains gone. He took X-ray check in the No. 1 People¨s Hospital of Huaihua, and the doctor said that he suffered protrusion of the lumbar intervertebral disc. 6 days ago, he worked in a construction site, pains over his lumbar happened again, with numbness and pains over his left lower limb. And he wanted comprehensive treatment of TCM, so he came to our hospital. He said he used to have a health body with no history of allergy of food or medicine.

3. When Pan Le came to our hospital, he suffered from evident pressing-pains over her lumbosacral portion, especially the left side. There were numbness and pains over his left lower limb, especially over his fourth and fifth toes. His spirit was not good. Appetite was bad. Sleep was just ok. Urination and bowel movement were normal.

4. T: 36.4＜C   R: 20 times/minute    P: 74times/minute   BP: 110/70mmHg

5. The patient grew normally with standard body shape. Her spirit activity was not good. He had no difficulty to walk. The size and formation of his thorax were normal. No enlargement with his heart. Rhythm of his heart was 74 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. His tongue was dark, with yellowish tongue coating. His pulse was wiry and thready.

Diagnostic Differentiation:

TCM:

The patient complained that he suffered from lumbar pains for 13 years, developed into numbness and pains over his left lower limb for nearly 6 days. TCM differentiates pains from asthenic symptoms and excess symptoms. His pains mainly showed stabbing pains, and after some movement, the pains became severe, refusing to be pressed. This symptom belongs to the scope of excess one in TCM. The patient was a constructor, and due to laborious work, his lumbar part bore great pressure for a long time, and that caused the poor circulation of blood and qi. In TCM, stagnation leads to pains. His tongue was dark and red with yellowish tongue coating. His pulse was wiry and thready. According to the theory of TCM, his symptom was due to qi stagnation and blood stasis. Treatment strategy should be promoting blood circulation and removing blood stasis as well as freeing the channels and relieving pains.

Western Medicine diagnosis:

1. Stabbing pains over his lumbar for 13 years, developed into numbness and pains over his left lower limb for 6 days.

2. Pains over his left lumbar part were obvious.

3. X-ray examination showed lumbar intervertebral disc protrusion.

First Diagnosis:

TCM: Bi impediment.

Symptom identification: the stagnation of qi and stasis of blood.

Western medicine diagnosis: Prolapse of lumbar intervertebral disc and sciatica.

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Å care.

3. Common diet.

4. Pathogenesis: the stasis of qi and blood.

5. TCM strategy: promoting blood circulation and removing blood stasis as well as freeing the channels and relieving pains.

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

7. Acupuncture and massage: once a day

8. Have more medical examination if necessary.

Date: Jan. 23, 2013                                            Time: 9:30 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient said pains over his lumbar part were reduced somewhat. Numbness felt over the fourth and fifth toes of his left foot. There still were pains over his back when he walked, bended and got up from the bed. His spirit was not so good. Appetite was bad. Sleep was good. Urination and bowel movement were normal. His tongue was dark-red, with thin and yellowish tongue coating. It was slightly thick in the middle of his tongue. His pulse was wiry and thready. There was an obvious pressing pain point of the left L3. According to the X-Ray report, L4/L5 showed disc disease and L3/L4 showed vertebrae hyperostosis. From the view of TCM, Dr. Ming thought that the case of the patient could be diagnosed as impediment disease, due to the stasis of qi and blood. The treatment strategy for it would be to promote blood circulation and remove blood stasis as well as free the channels and relieve pains.

Date: Jan. 24, 2013                                            Time: 9:30 a.m.

The patient said lumbar pains were reduced. He could do more flexible activities.

Date: Jan. 26, 2013                                            Time: 9:30 a.m.

The patient said lumbar pains were reduced obviously. He could do more activities. Pains were reduced when he walked, got up from the bed or bended. Pains over his left thigh were gone.

Date: Jan. 30, 2013                                            Time: 9:30 a.m.

The patient felt further improvement in her lumbar pains. There was still numbness over his left toe. Today he was given a TCM plaster to stick to his L3/L4 painful point.

Date: Feb. 1, 2013                                              Time: 9:30 a.m.

The patient said that his lumbar pains were almost gone. There were no more pains over his back when he bended his back or squatted. Numbness still existed over his toes.

Doctor¨s advice after leaving hospital:

1. Avoid wind-cold, maintain good moods, and take care of the diet. 

2. Take herbal medicine back for continuing treatment.