Brief Summary: July 23, 2008, Fabienne, from Switzerland, who has suffered from lumbar pains for 5 years, was hospitalized in our hospital. After 16-day TCM treatment here, she felt that the lumbar pains in daytime disappeared. Furthermore, the pains at night lessened a lot. The patient felt very surprised at her improvement.

Record of Hospitalization

Name: Fabienne                                         Sex: Female

Age: 29                                                      Profession: Student

Birthplace: Switzerland                              Marital Status: Unmarried

Onset Season:  Winter                              Date of Admission: July 23, 2008  

Complainer: The patient herself                  Reliability: Reliable

First Medical Record

July 23, 2008  

Fabienne, a 29-year-old female, has suffered from lumbar pains for 5 years. She was hospitalized in our hospital for further treatment at 19: 00 p.m. on July 23, 2008.

Essentials for Diagnosis:

1. The patient has suffered from lumbar pains for 5 years.

2. The patient has suffered from achondroplasia since she was a child, which results in her dysostosis with short stature. Five years ago, she began to suffer from lumbar pains, especially obvious pains in the area of the double kidneys at night. Only after she took Dafalgan could she fall asleep slowly when she suffered from terrible pains at night. But she has never been cured. When the patient suffered from the lumbar pains, she always found it hard to fall asleep. What’s more, she felt lassitude all over the body, as well as dizziness, headache, and the feelings of ants shuttling her head and arms. Furthermore, her eyesight reduced with a symptom of double image. Her food intake was poor. Her bowel movement was normal with frequent urination.

3. T 36.4℃，P 84 beats/minute, R 20 times/minute, BP 120/80 mmHg.

4. She grew normally with common nourishment. Her mind was clear. She had an expression of chronic illness and languidness. Her body was in a positive posture and she was cooperative in examination.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 84 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. No pains in the area of the double kidneys on percussion. With dysostosis all over the body. Her tongue was pale with white tongue coating. Her pulse was string-like and slippery.  

7. Diagnostic examination:

Diagnostic Basis:

TCM (Traditional Chinese Medicine): The patient has suffered from lumbar pains for 5 years. When the patient suffered from the pains in the area of the kidneys at night, she always found it hard to fall asleep. What’s more, she felt lassitude all over the body, as well as dizziness, headache, and the feelings of ants shuttling her head and arms. Furthermore, her eyesight reduced with a symptom of double image. Her food intake was poor. Her bowel movement was normal with frequent urination. Her tongue was pale with white tongue coating. Her pulse was string-like and slippery. According to the symptoms of her tongue and pulse, because of the insufficiency of the qi and blood, obstruction of the network channels caused by cold-damp impediment made the patient suffer from the lumbar pains. Therefore, it is believed as impediment syndrome.

Western Medicine: The patient has suffered from lumbar pains for 5 years. The patient has suffered from achondroplasia since she was a child, which results in her dysostosis with short stature. What’s more, due to the different stress on the muscles on the both side of the loins, it results in lumbar pains gradually. Therefore, she was diagnosed with lumbar muscle strain.

Diagnostic Differentiation:

TCM (Traditional Chinese Medicine): The patient’s impediment syndrome should be differentiated from wilting syndrome. Impediment syndrome is generally characterized by aching pains, fixed heaviness and inflexibility of sinews and bones, muscles and joints, with occasional numbness or swelling, though, no paralytic manifestations exist. On the contrary, wilting syndrome is characterized by limp, weak, and emaciated limbs with muscular atrophy. A patient suffered from wilting syndrome seriously may even become unable to hold any objects or to stand without any support. Besides, the patient usually has no joint pains. They are not difficult to be distinguished in clinics.

Western Medicine: Impediment syndrome should be differentiated from lithangiuria, which also has a symptom of lumbar pains. But generally speaking, lithangiuria is always accompanied by unusual urination. Furthermore, B-ultrasonic can check out the urinary system stone. Therefore, they are not difficult to be distinguished in clinics.

First Diagnosis: 

TCM (Traditional Chinese Medicine) diagnosis: Impediment syndrome

Symptom identification: Insufficiency of the qi and blood, obstruction of the network channels.

Western Medicine diagnosis: 1. Lumbar Muscle Strain

                        2. Achondroplasia    

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Regular diet.

4. Herbal tea (to boost qi and nourish the blood, dispel damp, free the network channels and relieve the pains): one dosage a day and drink twice.

Main herbs used in the herbal tea: danggui (tangkuei), baishu (ovate atractylodes root), fuling (poria), etc.

5. Acupuncture and massage: once a day.

6. Have more medical examinations if necessary.

Date: July 24, 2008                               Time: 8:30 a.m.

Today the patient said to doctor Zhang that she had suffered from lumbar pains for 5 years. She has suffered from achondroplasia since she was a child, which resulted in her dysostosis with obviously shorter stature than normal people. Now, she complained about her lumbar pains, especially obvious pains on the both side of the loins at night, which seriously affected her sleep. What’s more, she felt lassitude all over the body, as well as dizziness, headache, and the feelings of ants shuttling her head and arms. Furthermore, her eyesight reduced with a symptom of double image. Her food intake was poor. Her bowel movement and urination were both normal. Dr. Zhang analyzed that the patient has suffered from achondroplasia since she was a child, which resulted in her dysostosis with short stature. What’s more, due to the different stress on the muscles on the both side of the loins, it resulted in lumbar pains gradually. Therefore, according to the above information, it was because of the insufficiency of the qi and blood, cold-damp impediment that the patient caught the disease. The TCM treatment strategy is to boost qi and nourish the blood, dispel damp, free the network channels and relieve the pains.

Date: July 25, 2008                               Time: 10:00 a.m.

Today the patient said that her condition kept steady. Her spirit was also improved. But there was no obvious improvement on the symptom of her lumbar pains at night. The patient told the doctor that she had had an operation on the hipbone at the age of 10. The results of the routine examinations were as follows: the examinations of blood, urine, ASO, ESR, and the function of the liver and kidneys were all normal. There was no obvious abnormality on the examinations of anterioposterior and lateral film of the loins and B-ultrasonic. The ECG showed: 1. sinus rhythm 2.Ⅰdegree atrio-neutricular block 3. anteroseptal myocardial infarction 4. ST segment depression

Date: July 26, 2008                               Time: 8:30 a.m.

Today the patient said that her sleep was not very good. Her spirit was improved a lot, so was the lassitude all over the body. But there was still no obvious improvement on the lumbar pains at night. Her food intake was normal, so were the bowel movement and urination. Her tongue was pale with white tongue coating. The pulse was string-like and slippery. It was considered that the damage of the hipbone caused that. The TCM treatment strategy was mainly to quicken the blood. Therefore, the prescription was changed as follows: huangqi (astragalus root), shudi (cooked rehmannia root), chuanqiong (ligusticum root), etc. 5 dosages in total.   

Date: July 31, 2008                               Time: 8:40 a.m.

Today the patient said that when she tried to sleep, her lumbar pains badly affected her sleep. Therefore, her spirit was slightly poor. Her food intake was normal, so were the bowel movement and urination. Her tongue was pale with white tongue coating. The pulse was string-like. Her prescription was changed as follows: chishao (red peony root), taoren (peach kernel), duzhong (eucommia bark), etc. 2 dosages in total.

Date: Aug. 2, 2008                               Time: 8:40 a.m.

The patient still told the doctor that there was no obvious improvement on the lumbar pains at night. The patient consciously felt there was a feeling of fever on her cheek and the palms of her double hands. Her food intake was normal, so were the bowel movement and urination. Her tongue was pale with white tongue coating. The pulse was string-like. Her prescription was changed as follows: zaopi (cornus fruit), shanyao (dioscorea root), fuling (poria), etc. 3 dosages in total.

Date: Aug. 5, 2008                               Time: 8:40 a.m.

Today the patient told the doctor that her lumbar pains had been improved a lot the day before. But she still felt lassitude and somnolence. Her tongue was pale with white tongue coating. The pulse was string-like. His other conditions were all normal. The doctor added zhihuangqi (honey-fried astragalus) in the last prescription. 5 dosages in total.

Date: Aug. 7, 2008                               Time: 8:40 a.m.