Brief Summary:
On Dec. 17, 2008, Jacqueline, from USA, who has suffered from
waist pains accompanied by numbness and pains of the lower limbs
for one year, was hospitalized in our hospital. She has achieved
significant improvement after 16 days TCM treatment here.
Record of Hospitalization
Name:
Jacqueline Sex: Female
Age:
52 Marital
Status: Married
Nationality:
USA Date of Admission: Dec.
17, 2008
Complainer:
The patient herself
First Medical Record
Date: Dec. 17, 2008 Time:
14: 00 p. m.
Jacqueline, a 52-year-old female, has suffered from waist pains
accompanied by numbness and pains of the lower limbs for one
year. She was hospitalized in our hospital for treatment at 14:
00 p. m. on Dec. 17, 2008.
Essentials for Diagnosis:
1.
The patient has suffered from waist pains accompanied by
numbness and pains of the lower limbs for one year.
2.
The patient had hysteromyoma for 20 years, so she had been given
two times of hysteromyomectomia operation. But it recurred
later. Presently she felt obvious pains on the right side of her
waist. There was the phenomenon of waist pains after 20 minutes
sitting. She had no history of trauma. Sometimes she had no
feeling of her lower limbs when sleeping, and sometimes she felt
numbness and pains when walking and lying down. There were
symptoms of abdominal pains, abdominal distention, acid reflux,
and indigestion. Sometimes she had abdominal pains, dry mouth,
yellow urine, constipation for 2-3 days per time and difficulty
in passing stool.
3. T 36.2℃,
P 58 times/minute, R 20 times/minute, BP 130/80 mmHg
4.
She grew normally with common nutrition. Her mind was clear. She
had natural expression. Her body was in a positive posture and
she was cooperative with clear mind.
5. No
thoracic deformity. Sound of breath was bilaterally normal on
auscultation. No sound of pleural friction. Heart border was
normal. Heart beat was 58 times/minute. Cardiac rhythm was
regular. No pathological murmurs on auscultation.
6.
There were no pressing pains and rebound tenderness on her
abdomen. No deformity of her spine. There were no tapping pains
on the area of her kidneys. Her tongue was pale tender-soft with
teeth marks on the edges of the tougue. Her tongue coating was
thin and white. Her pulse was thready and weak.
7. Accessory
examination.
Diagnostic Basis:
TCM: The patient has suffered from waist pains accompanied by
numbness and pains of the lower limbs for one year. Presently
she felt obvious pains on the right side of her waist. Sometimes
she had no feeling of her lower limbs when sleeping, and
sometimes she felt numbness and pains when walking and lying
down. The main symptom focused on the joint pains of her limbs,
so it was not difficult to be diagnosed with impediment pattern.
Western Medicine:
1. The patient has suffered from waist pains accompanied by
numbness and pains of the lower limbs for one year.
2. No deformity of her spine. There were no tapping pains on the
area of her kidneys.
Diagnostic Differentiation:
TCM (Traditional Chinese Medicine): The patient’s impediment
syndrome should be differentiated from wilting syndrome.
Impediment syndrome is mainly characterized by aching pains,
fixed heaviness and inflexibility of the sinews and bones, the
muscles and joints, but no paralytic manifestations exist. While
wilting syndrome is characterized by limp, weak and emaciated
limbs with muscular atrophy. A patient suffering from wilting
syndrome seriously may even become unable to hold an object and
stand. But the patient usually has no joint pains. So they are
not difficult to be distinguished.
Western Medicine: Impediment syndrome should be differentiated
from urinary calculus which will result in the phenomenon of
waist pains usually accompanied by abnormal urination. Besides,
there will be urinary system stone by B ultrasound examination.
First Diagnosis:
TCM (Traditional Chinese Medicine): Impediment syndrome
Symptom identification: Insufficiency of the liver and kidney,
obstruction of the channels and network vessels.
Western Medicine diagnosis:
1. Strain of lumbar muscles
2. Hysteromyoma
3.Chronic gastritis should be diagnosed further
Plans for treatment strategy and nursing:
1. Routine
care of traditional Chinese internal medicine.
2. Grade
II care.
3. Common
diet.
4. TCM
strategy: Supplement the liver, boost the kidneys, boost qi,
quicken the blood and free the network vessels.
5. Main
herbs used in the herbal tea: baishao (white
peony root), baizhu (ovate atractylodes root), chenpi (tangerine
peel), etc. One dosage a day and drink twice.
6. Acupuncture
and massage: once a day.
7. Have
more medical examinations if necessary.
Date: Dec. 18, 2008 Time:
8: 40 a. m.
The patient complained that she had suffered from waist pains
accompanied by numbness and pains of the lower limbs for one
year. She was not given the other examinations. Presently she
felt waist pains especially the right side. Sometimes she had no
feeling of her lower limbs when sleeping, and sometimes she felt
numbness and pains when walking and lying down. There were
symptoms of abdominal pains, abdominal distention, acid reflux,
and indigestion. Sometimes she had abdominal pains, dry mouth,
yellow urine and constipation. Her tongue was pale tender-soft
with indentation. Her tongue coating was thin and white. Her
pulse was fine and weak. According to the symptoms of her tongue
and tongue coating, Professor Yang believed that her waist pains
were due to vacuity and obstruction of qi and blood. So the
treatment strategy was to boost qi, quicken the blood, free the
network vessels and relieve pains.
Date: Dec. 19, 2008 Time:
9: 00 a. m.
The patient said that her waist pains had lessened. She felt
slight numbness and tiredness of the right lower limbs. Sleep
was normal. She didn’t feel mouth dry. There were no symptoms of
abdominal pains and abdominal distention. The urination and
bowel movement were normal. According to the feedback of today’s
examination, Blood R was normal. Urine R showed RBC +/HP and
occult blood 2+. The function of the liver was ALT 52U/L. There
was no abnormity of her waist through the X–ray examination. The
ECG showed she had sinus irregularity. So the doctor added some
ingredients to stanch bleeding and quicken the blood, the
prescription was as follows: diyu (sanguisorba
root), honghua (carthamus flower), etc. 4 dosages in total.
Date: Dec. 20, 2008 Time:
8: 40 a. m.
Her spirit and sleep were good. Her urination and bowel movement
both were normal. The pains in her waist disappeared. The
patient didn’t feel the weakness of the lower limbs. So she
continued to take the previous herbal tea. 4 dosages in total.
Date: Dec. 28, 2008 Time:
10: 00 a. m.
The patient said her diet and sleep both were normal. There were
no waist pains. 3 dosages in total.
Date: Dec. 31, 2008 Time:
9: 00 a. m.
Her sleep and spirit were good. Her urination and bowel movement
both were normal. The patient didn’t complain about the waist
pains and the numbness of the limbs. So the prescription was the
same as before. 2 dosages in total.
Date: Jan. 3, 2009
The patient decided to leave the hospital with taking 60 days
granules for further treatment. The prescription was as follows:
baizhu (ovate atractylodes root), mugua (chaenomeles fruit),
niuxi (achyranthes root), etc. One dosage a day.
