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Brief
Summary: On December 10,
2010, Seddiqa, from Bahrain, who had been suffering lumbar pains for 3 years,
developed into numbness and pains over her left lower limb for 1 year, was
hospitalized in our hospital. She achieved some great improvement after 58 days
TCM treatment.
Record
of Hospitalization
Name:
Seddiqa Sex: Female
Age:
48
Marital Status: Unmarried
Nationality: Bahraini
Date of Admission: Dec. 10, 2010
Companion: Her Mother
First
Medical Record
Date:
Dec. 10, 2010 Time: 9:30 am
This
48-year-old lady had been suffering from lumbar pains for 3 years, developed
into numbness and pains over her left lower limb for 1 year. The patient was
hospitalized in our hospital for TCM treatment at 19:40 pm on December 10, 2010.
Essential for Diagnosis:
1. The
patient had been suffering from pains over her lumbosacral portion for 3 years,
developed into numbness and pains over her left lower limb for 1 year.
2. The
patient complained of lumber pains due to work long time on the desk, and at
that time she did not pay much attention to that problem. 3 years ago, pains
over her lumbar became severe, and then she went to the Capital hospital of
Thailand for examinations. The MRI report presented that there was progressive
lesion on L3-S1 and ring shaped defects on L3-L5. In the left side of L5-S1,
there was compression of the dura mater of spinal cord and the left nerve roots.
At that time, the diagnosis from the hospital was lumbar intervertebral disc
protrusion. The doctor gave her some pain-killers, but the effects were not so
perfect. 13 years ago, because of abdominal pains, she went to the hospital for
examinations, which presented that there were five fibroids of different sizes
in her womb. She took the operation on these fibroids. But 4 years ago, the
fibroids occurred again, and the largest one was 3.2*2.1*3.7cm. There was cyst
in the right side of her ovary, with the size of 8.2*4*4.2cm. At present, she
did not take any treatment for her fibroids.
3. When
Seddiqa came to our hospital, she suffered from evident pressing-pains over her
lumbosacral portion and her left-side buttock. There were pains and stiffness
over her left lower limb. There were evident pressing-pains and rebound
tenderness over her abdomen. She had entered menopause for 3 years. She had
night sweating and paroxysmal fever. Her appetite and sleep were normal. Her
spirit was good. Her tongue was dark with yellow tongue coating. The root of her
tongue was a little bit bristle, with cracks along both sides of her tongue
body. Her pulse was weak. Bowel movement and urination were normal.
4. T:
36.3＜C R: 20 times/minute P: 56 times/minute BP: 108/62mmHg
5. The
patient was of chronic and sick complexion with painful facial expression. She
grew normally with standard body shape. Her spirit activity was normal. She had
no difficulty to walk, but there were pains over her left lower limb when she
was walking.
6. The size
and formation of her thorax were normal. No enlargement with her heart. Rhythm
of her heart was 56 times per minute. Heart rate was regular with no murmurs.
Sound of breathing in the lungs was clear, without any
rhonchi.
7. MRI of June 19, 2010, showed
that she had been suffering from
lumbar intervertebral disc protrusion.
Diagnostic Basis:
TCM:
The patient had suffered from lumbosacral pains for three years, accompanied by
numbness and pains over her left lower limb and left-side buttock. There were
evident pressing-pains over her abdomen. From the view of TCM, when the channels
are obstructed, there would be pains, and therefore, the qi and blood in the
body will be damaged. In addition, if people are sick for too long, there would
appear more deficiency and more stasis. So, from this point of view, her tongue
was dark with yellow tongue coating. The root of her tongue was a little bit
bristle, with cracks along both sides of her tongue body. Her pulse was weak.
Therefore, her conditions could be diagnosed as Bi impediment.
Western
Medicine: There were pains
and numbness over her lumbosacral portion and left-side lower limb. And
according to her MRI report, her condition could be diagnosed as prolapse of
lumbar intervertebral disc.
Diagnostic Differentiation:
TCM:
Bi impediment is usually differentiated from wilting pattern. Wilting pattern
may have the symptom of atrophy and weakness of muscles, with no joint pains.
So, it is easy to differentiate them.
Western
Medicine diagnosis: Her
condition should be differentiated with apoplectic sequela.
Apoplectic sequela has the main symptom of motion limitation of the limbs on one
side of the body. Limbs of the patient are weak, with no pains at the early
stage of the disease. Therefore, there is no difficulty to differentiate them.
First
Diagnosis:
TCM: Bi
impediment and Carbuncle.
Symptom
identification: the stasis of qi and blood as well as
the blockage of channels and network channels.
Western
medicine diagnosis: Prolapse of lumbar intervertebral disc.
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 as well as the blockage of channels and
network channels.
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: Dec.
11, 2010 Time: 9:00 am
Professor
Zhang Xiukui paid a visit to the patient. The patient complained of evident
pressing-pains over her lumbosacral part and her left buttock. Her left lower
limb was numb and painful. Pressing-pains over her left knee were obvious.
Evident pressing-pains and rebound pains also appeared on her abdomen and lower
legs. She had entered menopause for 3 years. She had night sweating and
paroxysmal fever. Her appetite and sleep were normal. Her spirit was good. Her
tongue was dark with yellow tongue coating. The root of her tongue was a little
bit bristle, with cracks along both sides of her tongue body. Bowel movement and
urination were normal. Her pulse was weak. From the view of TCM, professor Zhang
thought that the case of the patient could be diagnosed as Bi impediment, due to
the stasis of qi and blood as well as the blockage of channels and network
channels. 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: Dec.
12, 2010 Time: 10:00 am
The patient
said there were pains over her both shoulders. Physical check: BP: 110/70mmHg.
Her heart rate was slow with regular heart rhythm of 58 times per minute.
Pressing pains on the middle parts of her shoulders were evident.
Date: Dec.
14, 2010 Time: 10:00 am
The patient said pains over her shoulders were
reduced a lot. There was no evident improvement in her lumbosacral pains and
pains over her left lower limb.
Paroxysmal fever, night sweating and dry
taste in her mouth improved a little bit. Sleep was not good. Her spirit was ok.
Her tongue was dark with yellow tongue coating. Root of her tongue was a little
bristle. There were cracks along both sides of her tongue body. Her pulse was
thready and weak.
Date: Dec.
20, 2010 Time: 10:00 am
The patient
felt further improvement in her shoulder pains. There still was no evident
improvement in her lumbosacral pains and pains over her left lower limb.
Paroxysmal fever, night sweating and dry taste in her mouth improved a little
bit. Pressing pains over her abdomen were relieved. Her tongue was dark red with
yellow tongue coating. The side of her tongue was dry with cracks. Her pulse was
thready and weak.
Date: Dec.
24, 2010 Time: 10:00 am
The above
mentioned conditions were improved better a little bit.
Date: Dec.
28, 2010 Time: 10:00 am
The patient
complained of no evident improvement in her lumbosacral pains, but it was better
than before she came to our hospital. Night sweating and paroxysmal fever
further improved. There were still pains over her legs, but better than before.
Her tongue was red with thin and yellow tongue coating. Tongue cracks were
reduced. Her pulse was thready and weak.
Date: Dec.
31, 2010 Time: 9:30 am
The patient
said pains over her lumbosacral part, left lower limb and her abdomen were
reduced a lot. Dryness in her mouth, sweating and paroxysmal fever still
existed. Pains over her shoulders almost dispelled. Her tongue was red with
yellow tongue coating. Her pulse was thready and weak. Heart rate was 64
times/minute.
Date: Jan.
4, 2011 Time: 10:00 am
The patient
said her conditions kept improving better. Her tongue was red with yellow tongue
coating. Her pulse was thready and weak.
Date: Jan.
8, 2010 Time: 11:00 am
Professor
Zhang paid a visit to the patient this morning. The patient said pains over
lumbosacral part and her left lower limb were reduced a lot. In recent days,
dryness in her mouth, sweating and paroxysmal fever improved obviously. Pains
over her abdomen were reduced. Her tongue was red with yellow tongue coating.
There were tongue cracks. Her pulse was thready and weak.
Date: Jan.
12, 2011 Time: 10:00 am
The patient
said her lumbar pains were reduced much. There were migratory pains over the
outer side of her left lower limb. Dryness in her mouth, night sweating and
paroxysmal fever kept changing better. Discontinuous pains appeared on her
abdomen. Today¨s MRI presented that there was a fibroid with size of 3*2cm on
the uterine wall. The cyst in the right side of her ovary was 5*3.8 cm. After
TCM treatment for one month, there was no big change in the size of the fibroid,
but the size of the cyst in the right side of her ovary was shrinking. Her
tongue was red with thin and yellow tongue coating. There were tongue cracks.
Her pulse was thready and weak.
Date: Jan.
16, 2011 Time: 10:00 am
The patient said pains over her left lower limb
sometimes were less, and sometimes were more.
Other
conditions kept changing better.
Date: Jan.
20, 2011 Time: 10:00 am
Pains over
lumbosacral part and left lower limb were reduced. Night sweating and paroxysmal
fever improved. The frequency of her abdominal pains became lower. In the recent
days, the patient had a sense of scary when slept at the night.
Date: Jan.
24, 2011 Time: 10:00 am
The patient
said the abovementioned conditions improved. Her sense of scary during her
sleeps was reduced.
Date: Jan.
28, 2011 Time: 10:00 am
The patient
said pains over her left lower limb sometimes were less, and sometimes were
more. Recently, she did not suffer abdominal pains. Night sweating and
paroxysmal fever were not severe.
Date: Jan.
31, 2011 Time: 10:00 am
The patient
said her conditions changed better recently.
Date: Feb.
5, 2011 Time: 10:30 am
The patient
said her conditions were stable these days.
Date: Feb.
6, 2011 Time: 10:30 am
Seddiqa
decided to leave the hospital today. After nearly 2 months TCM treatment here in
our hospital, she achieved some improvement in her conditions. Pains over her
lumbosacral part and her left lower limb were reduced. Pressing pains and
rebound pains over her abdomen were almost cured. Paroxysmal fever, night
sweating and dry taste in her mouth were improved a lot. The MRI report of
January 12, 2011 presented that the largest fibroid now was 3*2cm with clear
edge lines. The cyst in the right side of her ovary was 5*3.8 cm now. Its size
shrank evidently.
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.
3. Keep
doing exercises. |
