Name: Ms.
Zhang Li
Sex: Female
Age: 38
Marital Status: Married
Nationality: China
Date of Admission: April
5, 2016
Companion: Alone
First Medical Record
Date: March
23, 2016 Time: 11:30
a.m.
This
38-year-old woman had been suffering from repeated pain over her
left hip for 10 years, being severe for 14 days. The patient was
hospitalized in our hospital as a patient with myofascitis for
TCM treatment at 9:30 a.m. on April 5, 2016.
Essential for Diagnosis:
1. The
patient said 10 years ago she had pain over her left hip since
she was working at her desk for a long time and prolonged
sitting. She took the painkiller to relief the pain. In recent
years, the interval time of pain between each time was shorter
and more frequent. And the pain often accompanied with numbness
over her left lower limb. The patient came to our hospital for
TCM treatment. There was medical history of periathritis of
shoulder for 2 years and iron deficiency anemia. And she also
had history of abnormal menstruation and cerebral arterial
spasm.
2. When
the patient came to our hospital, she suffered stabbing pain
over her left hip, accompanied with numbness over her left lower
limb, being severe when she moved her left leg. There was pain
over her left shoulder joint, the activity was slightly limited.
Occasionally she had headache and dry mouth. She was in good
spirit. The appetite and sleeping were good. The urination was
normal, the color of urine was slight yellow.
3. T:
36.5＜C R: 20 times/minute P: 70 times/minute BP:
100/60mmHg
4. The
patient grew normally. She was alert and cooperative. She had
chronic sick facial complexion. She walked slowly. There was no
sign of yellow sclera or yellowish skin and also no enlargement
on the superficial lymph node of her whole body.
Diagnostic Differentiation:
TCM:
Impediment, Stagnation of qi and stasis of blood.
Western Medicine diagnosis:
1.
myofascitis
2.
periathritis of shoulder
3. iron
deficiency anemia
4.
cerebral arterial spasm
5.
abnormal menstruation
Treatment strategy and nursing:
1.
Routine care of traditional Chinese internal medicine.
2.
Grade Å care,
common diet, avoid spicy food.
3.
Completed the related examination,
three routine inspection, the function of the kidneys and the
liver, HB 5 test, blood fat, blood sugar, anti-O, RF and IMX.
4.
Herbal tea: one dosage a day and drink twice
5.
Acupuncture and massage: once a day.
6.
Avoid wind-cold, regular daily life, have a good mood and take
care of diet.
Date:
April 06, 2016 Time:
10:00 a.m.
Dr. Luo,
doctor-in-charge, paid a visit to the patient. The patient
complained suffered stabbing pain over her left hip, accompanied
with numbness over her left lower limb, being severe when she
moved her left leg. There was pain over her left shoulder joint,
the activity was slightly limited. Occasionally she had headache
and dry mouth. She was in good spirit. The appetite and sleeping
were good. The urination was normal, the color of urine was
slight yellow. The bowel movement was normal.
The tongue body wasdark red with thin coating. The pulse was
wiry and weak. The tongue body wasdark red with thin coating.
The pulse was wiry and weak.
Date:
April 07, 2016 Time:
10:00 a.m.
The
patient said the stabbing pain and numbness over her left hip
and left lower limb slightly relieved. The pain over her left
shoulder joint improved. The other symptoms was almost the
same. There was no obvious improvement. Taking the herbal tea to
observe the effect.
Date:
April 08, 2016 Time:
10:00 a.m.
The
patient said the stabbing pain over her left hip and the
numbness of her left lower limb obviously improved. Doctor
adjusted the formula.
Date:
April 10, 2016 Time:
10:00 a.m.
The
patient said the stabbing pain over her left hip and the
numbness of her left lower limb became better day by day. While
she still had the pressing pain. The tongue body was rd with
thin coating. Continued the formula.
