Name: Ms. Yuan Jun                                                            Sex: Female

Age: 50                                                                                Marital Status: Married

Nationality: China                                                                Date of Admission: March 25, 2015

Companion: Alone

First Medical Record

Date: March 25, 2015                                    Time: 14:00 a.m.

This 50-year-old woman had been suffering from lumbago and powerlessness for 12 years, being severe for 8 months. The patient was hospitalized in our hospital as a patient with Prolapse of Lumbar Intervertebral Disc for TCM treatment at 09:00 a.m. on March 22, 2015.

Essential for Diagnosis:

1. The patient said 12 years ago she started to appear the pains over her low back because of her profession. She could not turn her body. She went to the Huaihua TCM Hospital to make a test. She was diagnosed with Prolapse of Lumbar Intervertebral Disc. She got the treatment with western medicine and TCM. Her condition was better. Yet in recent years, the lumbago repeated. In August of 2014, she had acute sever pains over her low back. She could not stand erectly and walk. It is difficult to turn over in bed. At that moment she got the treatment at Huaihua TCM Hospital, her condition improved. The patient want to the comprehensive TCM treatment, she came to our hospital for treatment. She had neuropathic insomnia history for 3 years and rheumatic arthritis for 7 years. She had no allergy history of any medicine or any food.

2. When the patient came to our hospital, she had following symptoms, such as dreaminess, insomnia and forgetfulness. And there was lumbago which lead her difficult to turn over. She had chilly limbs, weakness and pains over her knee-joints. And the pains were related with the changes of the weather. Whenever the weather was getting cold, the pains got worse. There were dizziness and headache. She had a poor spiritual status. Her appetite was good, and her urination and bowel movement were normal.

3. T: 36.5＜C     R: 20 times/minute    P: 76 times/minute     BP: 140/80mmHg

4. The patient grew normally. She was alert and cooperative. She had chronic sick facial complexion. There was no sing of yellow sclera or yellowish skin and also no enlargement on the superficial lymph node of her whole body. Facial features were normal with masses. There were pressing pains over her top of her head and tempora bond. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. There was no enlargement over her superficial lymph node. Her neck was soft. Her trachea was symmetrical. There was no enlargement over her thyroid. The jugular vein was of no engorgement. Her chest was symmetrical without deformity. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of her heart was 76 times per minute. Heart rate was regular with no murmurs. Her abdomen was soft with no pressing pains and rebound tenderness. There was no sign of deformity over her spine. There were pressing pains over her muscle from L1 to L5, and as well as her knee joints. The meningeal irritation sign was negative. There were no pathological reflections, but the physiological reflections existed. The tongue body was light red with white and thin coating. The pulse was deep and slippery.

Diagnostic Differentiation:

TCM: 1. Kidney deficiency

            2. Lumbargo

Western Medicine diagnosis:

1 neuropathic insomnia

2. Prolapse of Lumbar Intervertebral Disc

3. rheumatic arthritis

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Å care, Common diet.

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

Dr. Luo, doctor-in-charge, paid a visit to the patient. The patient complained that she had suffered from  pressure-relieved low back pains. It was difficult to turn over in bed. There were weakness, chilly limbs, pains of knee-joints, dizziness, headache, dreaminess, insomnia and forgetfulness. She just could sleep about 3 to 5 hours per night, she was easy to wake with a start. Her appetite was good, and her urination and bowel movement were normal. The tongue body was light red with white and thin coating. The pulse was deep and slippery.

The vital signs of the patient were stable. The patient said that after treatment, the low back pains slightly relieved. There were no other changes.

The patient said the lumbago was much better. And she felt the power increased. And the dizziness and headache relieved. Yet she still had dreaminess, poor sleeping and spirit. Her pulse was deep and slippery. The results of the examination showed, three routine inspection and ESR were normal. And the function of kidneys was normal. The function of liver: ALT 61 IU/L ●; Adjusted the formula according to her test report.

The patient said the pains improved obviously. The dizziness and headache disappeared. Her sleeping was better. Adjusted the formula again.

Date: Apr. 03, 2015                                            Time: 10:00 a.m.

The vital signs of the patient were stable. The patient said there were about 80% improvements on the low back pains. The pains over her lumbar vertebra relieved. 

Date: Apr. 05, 2015                                            Time: 10:00 a.m.

The patient said the pains improved day by day. And the power of her body increased. The temperature of her four limbs increased as well. The pains of her knee-joints relieved. The dizziness and headache disappeared completely. Her spirit state was good. Her sleeping and appetite were normal. The tongue body was red with thin and white coating. The pulse was deep ad wiry.

Date: Apr. 07, 2015                                            Time: 10:00 a.m.

After 15 days TCM treatment with the help of herbal tea, acupuncture and massage, the patient¨s condition got great progress. The patient decided to leave the hospital today. In order to consolidate the effect, the patient took the herbal tea back.