Name: Shi Xianzhou                                                    Sex: Male

Age: 60                                                                       Marital Status: Married

Nationality: China                                                       Date of Admission: Apr. 15, 2015

Companion: Alone 

First Medical Record 

Date: April 15, 2015                                Time: 10:30 a.m. 

This 60-year-old man had been suffering from pains over his lumbar for ten years, companied by numbness over his left leg for more than ten years, and being severe for 3 months. The patient was hospitalized in our hospital as a patient with Prolapse of Lumbar Intervertebral Disc for TCM treatment at 10:30 a.m. on April 15, 2015. 

3. T: 36.8＜C   R: 20 times/minute    P: 66 times/minute   BP: 140/70mmHg 

4. The patient grew normally with standard body shape. He was alert and cooperative. He had chronic sick facial complexion. He was in compulsive position. There was  no sign of yellow sclera or yellowish skin and also no enlargement on the superficial lymph node of his whole body. His neck was soft without resistance. His trachea was symmetrical. Facial features were normal with masses. There was no enlargement over his thyroid. The jugular vein was of no engorgement. His chest was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 66 times per minute. His abdomen was soft with no pressing pains and rebound tenderness. There was no obvious swelling, yet with slight pressing pains. There was no sign of derformity over his spine. There was obvious pressing pains aroung his lumber vertebra. Elevation test of straight left leg (+), Bragard Test (+). The meningeal irritation sign was negative. There were no pathological reflections, but the physiological reflections existed. His tongue was dark red with yellow tongue coatings. His pulse was string, deep and powerful.

Diagnostic Differentiation:

TCM: Lumbargo

Western Medicine diagnosis:

Prolapse of Lumbar Intervertebral Disc

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Å care, Common diet, monitoring the blood pressure, once a day.

3.Sleep on a hard bed. Avoid wind-cold, regular daily life, have a good mood and take care of diet.

4. Completed the related examination, three routine inspection, the function of the kidneys and the liver, blood fat, blood sugar, anti-O, RF and IMX..

5. Herbal tea: one dosage a day and drink twice

6. Acupuncture and massage: once a day

Date: Apr. 16, 2015                                            Time: 9:00 a.m.

Dr. Zhu Ming, doctor-in-charge, paid a visit to the patient this morning. The patient complained that he had suffered from the pains over his lumbar because of lumbar sprain ten years ago. He did not care this problem. He just put some plasters upon his lumbar, and the symptoms relieved at that moment. Later the lumbago repeated, and the condition was getting worse day by day. He could not bend and even could not turn over his body. Recent years, he felt the numbness of his left leg, and it radiated to the sole. Sometimes there were sore and distent pains around hip joints. He felt difficult to sit, stand and walk for a long time. He felt cold, while his skin was hot. He could not turn over his body in bed. Sometimes he had dizziness and headache. It was not related with the weather changes. There was no tinnitus. His appetite was good, the urination and bowel movement were normal. Body checked, there were obvious pressing pains over his lumbar. Elevation test of straight left leg (+),Bragard Test (+).His tongue was dark red with yellow tongue coatings. His pulse was string, deep and powerful.

Date: April 19, 2015                                            Time: 9:00 a.m.

The patient said that after treatment, the pains over his lumbar slightly relieved. And the numbness also improved. It was better for bending and stretching his waist. And it was much easier for walking. His sleeping and appetite were good. The urination and bowel movement were normal. The tongue coating was yellow. The pulse was string, slow, deep and powerful. 

The vital signs of the patient were stable. The patient said the lumbago obviously improved. And the pains over his knees relieved. The pressing pains around his lumbar vertebra obviously relieved. The tongue coating was white, the pulse was deep and string.

The patient was in good spirit status. The patient said the lumbago improved greatly, yet he still could not walk as normal. When walking, his body created a little bit of tilt. The pains over his knee-joints disappeared. Elevation test of straight left leg still was positive. The tongue coating was white, the pulse was deep and string.