Brief Summary:
On April 12, 2013, Yang Changpo, from the village of Yuanjia,
who had been suffering lumbar pains for moe than one year, was
hospitalized in our hospital. Her condition became severe in the
recent two months. She achieved great improvement only after
nearly 10 days TCM treatment with the help of Acupuncture,
Herbal tea and Tuina in our hospital.
Record of Hospitalization
Name:
Yang Changpo
Sex: Female
Age:
40 Marital Status: Married
Nationality:
China Date of Admission: Apr. 12, 2013
Companion:
Alone
First Medical Record
Date:
April. 12, 2013 Time:
11:00 a.m.
This 40-year-old woman had been suffering lumbar pains for moe
than one year. Her condition became severe for 2 months. The
patient was hospitalized in our hospital for TCM treatment at
11:00 a.m. on April 12, 2013.
Essential for Diagnosis:
1. The patient had been suffering lumbar pains
for more than one year. Her condition became severe in the
recent 2 months. She was hospitalized in our hospital as a
patient due to prolapse of lumbar intervertebral disc.
2. The patient complained that one year ago, she
sprained her lumbar part during work, and then she suffered
pains over her lumbar part. She went to the No. 3 People¡¯s
Hospital for CT examination, and the result was prolapse of
lumbar intervertebral disc. She did not take any treatment, and
the doctor only advised her to stay on bed for rest. While in
the recent 2 months, she felt severe pains over her lumbar part,
and she could not even for any labor work. In order to seek help
from the TCM treatment, she came to our hospital.
3. When Ms. Yang came to our hospital, she suffered severe pains
over her back. She could not bend or lift her back. She could
not sit, lie, walk and stand for a long time. When she did some
work, she felt much more pains, and when she got rest, the pains
were relieved. Her pains were not related with the changes of
weather. Her urination and bowel movement were normal. There
were no pains and numbness over her lower limbs.
4.
T: 37.1¡ãC R:
24 times/minute P: 66 times/minute
BP: 110/74 mmHg
5. The patient grew normally with standard body shape. She was
alert and cooperative. She had chronic sick facial complexion.
There were no sign of yellow sclera or yellowish skin. There was
no enlargement on the superfacial lymph node of her whole body.
Facial features were normal. There was no enlargement on his
thyroid gland. Rhythm of his heart was 66 times per minute.
Heart rate was regular with on murmurs.
Sound of breathing in the lungs was clear, without any rhonchi.
There were obvious pressing pains over her fourth and fifth
lumbar vertebras. There was no numbness over her lower limbs.
There was light limitation on the movement of bending and
lifting her back. Her urination and bowel movement were normal.
Her tongue was red with yellowish tongue coatings. Her pulse was
thready and wiry.
Diagnostic Differentiation:
TCM:
The patient complained that one year ago, she sprained her waist
during works. Pains over her waist became severe day by day.
Though she bought medicines to reduce pains, but the effects
were not good. Long time of disease damaged the qi and blood in
her body, and the cold-pathogen intruded into her spinal column.
Therefore, she could not sit, lie, walk or stand for a long
time, and pains became severe when she did some work. Her tongue was red with yellowish tongue coating. Her
pulse was wiry, thready and unsmooth. According to the theory of
TCM, her symptom could be diagnosed as lumbar pain, which was
due to the deficiency of qi and blood and the stagnation of
coldness on the spinal column. Treatment strategy should be
warming and tonifying the kidney-yang, as well as promoting the
flow of qi and blood.
Western Medicine diagnosis:
1. Sprained waist for more than one year.
2. Pressing pains were obvious on her
fourth and fifth lumbar vertebras.
3. X-ray examination showed lumbar intervertebral disc
protrusion.
First Diagnosis:
TCM: Lumbar pain.
Symptom identification: the deficiency
of qi and blood and the stagnation of coldness on the spinal
column
Western medicine diagnosis: Prolapse of lumbar intervertebral
disc.
Treatment strategy and nursing:
1. Routine care of traditional Chinese internal medicine.
2. Grade
¢ò
care.
3. Common diet.
4. Pathogenesis: the deficiency of qi and blood and the
stagnation of coldness on the spinal column.
5. TCM strategy: warming and tonifying
the kidney-yang, as well as promoting the flow of qi and blood.
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: Apr. 13,
2013 Time: 09:30 a.m.
Dr. Ming, doctor-in-charge, paid a visit to the
patient. The patient complained that one year ago, she sprained
her waist during works. Pains over her waist became severe day
by day. Though she bought medicines to reduce pains, but the
effects were not good. She felt numbness over her lower limbs.
Body Check: T: 37.1¡ãC R: 24 times/minute P: 66times/minute
BP: 110/74mmHg. The patient grew normally with standard body
shape. She was alert and cooperative. She had chronic sick
facial complexion. There were no sign of yellow sclera or
yellowish skin. There was no enlargement on the superficial
lymph node of her whole body. Facial features were normal. There
was no enlargement on his thyroid gland. Rhythm of his heart was
66 times per minute. Heart rate was regular with no murmurs.
Sound of breathing in the lungs was clear, without any rhonchi.
There were obvious pressing pains over her fourth and fifth
lumbar vertebras. There was no numbness
over her lower limbs. There was light limitation on the movement
of bending and lifting her back. Her tongue was red with
yellowish tongue coating. Her pulse was wiry, thready and
unsmooth.
From the view of TCM, Dr. Ming thought that the case of the
patient could be diagnosed as lumbar pains, due to the
deficiency of qi and blood and the stagnation of coldness on the
spinal column. The treatment strategy for it would be to warm
and tonify the kidney-yang, as well as to promote the flow of qi
and blood.
Date: Apr. 14,
2013 Time: 09:30 a.m.
The patient said lumbar pains were reduced
slightly. The movement of bending and lifting her back was
improved. There was no other obvious discomfort. Her tongue was
red with yellowish tongue coating. Her pulse was wiry.
Date: Apr. 17,
2013 Time: 14:00 a.m.
The patient said
lumbar pains were reduced obviously. Her pulse was wiry and
slow.
Date: Apr. 19,
2013 Time: 10:00 a.m.
The patient said after these day TCM treatment,
lumbar pains were completely gone. She could bend and lift her
back flexibly. Vital signs of the patient were stable. Her pulse
was wiry and slow.
Date: Apr. 20,
2013 Time: 09:30 a.m.
When paid visit to the patient, the patient said lumber pains
were completely gone. She could bend and lift her back freely.
Vital signs of the patient were stable. There were no more
pressing pains over her fourth and fifth
lumbar vertebras. Functions were normal. Her
tongue was red. Her pulse was wiry and slow. The patient decided
to leave our hospital today.
Doctor¡¯s advice after leaving hospital:
1. Take enough rest, and avoid injury from work.
2. Take herbal medicine back for continuing treatment.
3. Pay attention to the diet. Avoid potato, beef
meat, bamboo shoots and fern brake.¡¡
