Brief
Summary:
On Jun. 9, 2009, Kamal from Sudan, who has suffered from lumbar
disc protrusion, Cotugno's disease and globulism, was
hospitalized in our hospital. He has achieved much improvement
after 34 days TCM treatment here. The HCT result of the blood
became normal after two weeks TCM treatment which made the
patient surprised.
Record of Hospitalization
Name:
Kamal Birthplace: Sudan
Sex:
Male Profession: Businessman
Age:
62 Date of Admission: Jun. 9, 2009
Nationality:
Sudan Date of
Record: Jun. 9, 2009
Marital Status:
Married Onset Season:
Summer begins
Complainer:
The patient himself
First Medical Record
Date: Jun 9, 2009 Time:
19: 00 p. m.
Kamal, a 62-year-old male, has suffered from lumbar disc
protrusion, Cotugno's disease and globulism. He was hospitalized
in our hospital at 19: 00 p.m. on Jun. 9, 2009.
Essentials for Diagnosis:
1. The
patient has suffered from the pains of the waist, buttocks and
right lower limb for 3 years and numbness of the left lower
limb.
2. In
June 2006, the patient began to feel the pains of the waist,
buttocks and right lower limb, numbness of the left lower limb
and swelling of the lower limbs without obvious reasons.
Besides, he felt that the pains gradually became worse when he
bent his back, raised his legs or walked. The condition had no
relation with the changes of the climate. So he went to a local
hospital and was diagnosed with lumbar disc protrusion and
Cotugno's disease. Then he was given some painkillers for the
treatment, but there was no much improvement. So he came to our
hospital for further treatment at 19: 00 p.m. on Jun. 9, 2009.
3.
T 36.2¡æ,
R 20 times/minute, P 88 times/minute, BP 136/88mmHg.
4. He grew normally with common nutrition. His mind was clear.
He had an expression of chronic illness and tiredness. His body
was in a positive posture and he 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 88 times/minute. Cardiac rhythm was
regular. No pathological murmurs on auscultation.
6. The patient felt the pains of the waist, buttocks and right
lower limb, numbness of the left lower limb and swelling of the
lower limbs. Besides, he felt that the pains gradually became
worse when he bent his back, raised his legs or walked. He could
not put one leg on the knee of the other side and raised the
stretched legs. His tongue was red-purple. His tongue coating
was pale yellow. His pulse was wiry.
7. Accessory examination: None.
Diagnostic Basis:
TCM: The patient has suffered from the pains of the waist,
buttocks and right lower limb for 3 years and numbness of the
left lower limb. Besides, he felt that the pains gradually
became worse when he bent his back, raised his legs or walked.
Poor movement of qi and blood especially the obstruction
resulted in the pains. His tongue was red-purple. His tongue
coating was pale yellow. His pulse was wiry. According to the
symptoms of his tongue and pulse, he was diagnosed with
impediment pattern.
Western Medicine: The patient has suffered from the pains of the
waist, buttocks and right lower limb for 3 years and numbness of
the left lower limb. Besides, he felt that the pains gradually
became worse when he bent his back, raised his legs or walked.
The condition had no relation with the changes of the climate.
He could not put one leg on the knee of the other side and
raised the stretched legs. He was diagnosed with lumbar disc
protrusion and Cotugno's disease in the local hospital.
Diagnostic Differentiation:
TCM: The patient¡¯s impediment pattern should be differentiated
from wilting pattern, which is mainly characterized by limp,
weak and emaciated limbs with the numbness of the muscles. If
the condition becomes serious, the patient can not grasp
anything or stand. But usually the patient has no joint pains
and these symptoms are mostly limited to the lower limbs. So
they are not difficult to be distinguished.
Western Medicine: The patient¡¯s lumbar disc protrusion should be
differentiated from pyriformis syndrome. If one suffers from
pyriformis syndrome, the patient will feel pains on the buttocks
and thighs. The pressure pain point lies in the buttocks and the
muscles on the buttocks will be atrophic The tensure test of
pyriformis shows ¡°+¡±. So they are not difficult to be
distinguished.
First Diagnosis:
TCM diagnosis: Impediment pattern
Symptom identification: qi stagnation and blood stasis, yin
vacuity of the liver and kidneys.
Western Medicine diagnosis: 1. Lumbar disc protrusion
2. Cotugno's disease
3. Hypertension
4. Globulism
Plans for treatment strategy and nursing:
1. Routine
care of traditional Chinese internal medicine.
2. Grade
II care.
3. Under
the care of a companion.
4. Low-fat
diet.
5. TCM
treatment strategy: move qi, quicken the blood circulation, free
the channels and network vessels, soften the liver, supplement
the kidneys and nourish yin.
6. Herbal
tea: one dosage a day and drink twice.
Main herbs used in the herbal tea: baishao (white
peony root), dangshen (codonopsis root), etc.
7. Acupuncture
and massage: once a day.
8. Have
more medical examinations if necessary.
Date: Jun. 10, 2009
The patient has suffered from the pains of the waist, buttocks
and right lower limb for 3 years, numbness of the left lower
limb and swelling of the lower limbs. Besides, he felt that the
pains gradually became worse when he bent his back, raised his
legs or walked. The condition had no relation with the changes
of the climate. He was diagnosed with lumbar disc protrusion and
Cotugno's disease in the local hospital and took some
painkillers for the treatment. Moreover, the patient has
suffered from hypertension for 20 years and has been taking
Lisinopril Tablets, Aspirin,
etc. In 2001, he was diagnosed with globulism, accompanied with
the symptoms of occasional fever all over the body, dry mouth,
red face and stasis macules on the forehead and lower limbs. His
tongue coating was pale yellow. His tongue was red-purple. Some
part of the tongue became black, and the patient said it was due
to the western medicine. His pulse was wiry.
TCM diagnosis: Impediment pattern
Symptom identification: qi stagnation and blood stasis, yin
vacuity of the liver and kidneys.
Western Medicine diagnosis: 1. Lumbar disc protrusion
2. Cotugno's disease
3. Hypertension
4. Globulism
TCM treatment strategy: move qi, quicken the blood circulation,
free the channels and network vessels, soften the liver,
supplement the kidneys and nourish yin.
Prescription: baishao (white peony
root), dangshen (codonopsis root), etc. 3 dosages in total.
Date: Jun. 12, 2009
He was given the routine examinations of the blood, urine and
bowel movement, the function of the liver and kidneys, E4A,
Triglyceride,
etc. His Hb was 18.2 g/L and the number of RBC (5.62¡Á1012
/L) was a little high. The other was normal. ECG showed that
there was no abnormity. The former prescription was changed a
little. 3 dosages in total.
Date: Jun. 16, 2009
The swelling of the lower limbs lessened. The pains of the waist
and legs were improved, but there were obvious pains when he did
some exercises. Professor Zhang suggested him to take MRI
examination on his
lumbar spine and cervical spine. He had deafness and tinnitus,
but there were no symptoms of headache, dizziness and dry mouth.
His sleep was good. His diet was normal. The prescription was
changed as follows: chuanxiong (ligusticum
root), duhuo (duhuo angelica root), etc. 4 dosages in total.
Date: Jun. 17, 2009
Yesterday he was given MRI examination which showed that he had
degeneration and hyperosteogeny of lumbar spine, degeneration
and bulge of each intervertebral disc of lumbar spine. The
examination of cervical spine showed that he had hyperosteogeny
of cervical spine and herniation of cervical disc. Some of his
cervical discs were
tortuous and deformative.
According to his condition, the pains could be relieved after a
long period of treatment of moving qi, quickening the blood
circulation, soothing the sinews and quickening the channels and
network vessels.
Date: Jun. 24, 2009
The waist pains lessened and he was given the routine
examination of the blood. His
RBC, Hb,
HCT became
normal. Continue to take the same prescription. 5 dosages in
total.
Date: Jun. 25, 2009
The patient was very glad that the routine examination of the
blood was normal and he said he never had such good result in
the recent 8 years. His blood pressure was 120/80mmHg. The
patient required to reduce the dosage of the hypotensive drugs.
According to his current condition, Professor Zhang agreed to
reduce one tablet of
vasodiiatotors and hypotensive drugs separately for further
observation.
Date: Jun. 29, 2009
The patient reduced one tablet of his hypotensive drugs for 3
days. His blood pressure was 120/70-80mmHg, which was basically
normal. The waist pains lessened. The prescription was changed
as follows: huangqi (astragalus
root), gancao (licorice root),
etc. 5 dosages in total.
Date: Jul. 3, 2009
His blood pressure was normal (120-130/70-80mmHg) since he
reduced one tablet of his
hypotensive drugs. Besides, he said
he forgot to take hypotensive drugs yesterday and today his
blood pressure was 130/80mmHg. He could reduce another tablet of
his
hypotensive drugs and the western
medicine used to reduce RBC if it was required. The waist pains
were up and down. It became more serious after tiredness. The
prescription was as follows: danpi (moutan
root bark), honghua (carthamus flower), etc. 4 dosages in total.
Date Jul. 8, 2009
The waist pains were further improved. The routine examination
of the blood showed that his
RBC, Hb,
HCT were
normal. His blood pressure was normal (130/80mmHg).
He decided to leave the hospital with taking 2 months herbal tea
back to home for continuous treatment. The prescription was
changed as follows: chuanxiong (ligusticum
root), taoren (peach kernel), etc. 3 dsoages in total.
Date: Jul. 10, 2009
After the comprehensive treatment including herbal tea,
acupuncture and massage for 1 month, the pains of the waist and
legs were obviously improved. His blood pressure was stable
(130/80mmHg). There were no symptoms of headache and dizziness.
His
erythremia completely became normal. Two times of examination
showed that his
RBC,
Hb,
HCT were normal. The patient was extremely
excited because the condition was never normal during the recent
8 years. He decided to leave the hospital with taking 2 months
herbal tea back to home for continuous treatment.¡¡
