Record of Hospitalization

Name: Yin Anmei                                                          Sex: Female

Age: 57                                                                         Marital Status: Married

Nationality: China                                                        Date of Admission: Jan. 8, 2013

Companion: Alone

First Medical Record

Date: Jan. 8, 2013                               Time: 10:30 a.m.

This 57-year-old lady had been suffering from lumbosacral pains for 12 year, developed into numbness over her left lower limb for two months. The patient was hospitalized in our hospital for TCM treatment at 9:00 a.m. on January 8, 2013.

Essential for Diagnosis:

1. The patient had been suffering from lumbosacral pains for 12 years, developed into numbness over her left lower limb for two months.

2. The patient complained that she suffered from lumbosacral pains after heavy work 12 years ago, accompanied with numbness and swelling pains over her left lower limb. She once took an X-Ray examination in No. 5 People’s Hospital, which showed that she was attacked by lumbar degenerative diseases. She was given some external-use plasters and some TCM herbal products, but the curative effects were not good. In the recent 2 months, due to overworks, her pains became severe. She has the history of chronic gastritis. She did the operation of hysterectomy 13 years ago.

3. When Mrs. Yin came to our hospital, she suffered from lumbosacral pains, accompanied by numbness and pains over his left lower limb. When pains happened, there was burning heat over her lumbar painful part. Feeling over her soles was decreasing. She felt bitterness in her mouth. She suffered stomach distension, nausea, hiccup and vomit with clear mouth water occasionally. There were murmurs over her gastral cavity. She always felt cold over her both feet. The patient sometimes suffered palpitations, but with no chest depression or chest pains. Her spirit and appetite were good. Urination and bowel movement were normal.

4. T: 36.3°C   R: 20 times/minute    P: 62times/minute   BP: 120/80mmHg

5. The patient grew normally with standard body shape. Her spirit activity was good. Her skin and sclera showed no symptom of yellow staining. There was no enlargement of her lymph gland and thyroid gland. Rhythm of his heart was 62 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. Her abdomen was soft, without any pressing pains and rebound tenderness. There were no percussion pains over his kidneys parts. Pressing pains exists over her left-side back and left buttock. Her tongue was red, with yellowish tongue coating. Her pulse was thread and weak.

Diagnostic Differentiation:

TCM:

The patient complained that she suffered from lumbar pains for 12 years, developed into numbness and pains over her left lower limb for nearly 2 months. Therefore, her condition could be diagnosed as lumbar pains. Long-time laborious work caused muscle strain over the patient’s lumbar muscles. She felt very weak over her lumbar muscles. She had the medical history of lumbar pains for 12 years. According to the theory of TCM, the waist is the renal government office. Continuous back pains are reflection of kidney deficiency，especially of deficiency of kidney-yin. So, she had the symptoms of dryness and bitterness in her mouth, yellow urine, and red tongue with yellowish tongue coating. The kidney dominates bone and hides essence. Kidney deficiency leads to loss of nourishment to the bones and muscles; therefore, numbness and pains happened over her limbs. According to the theory of TCM, her symptoms should be diagnosed as lumbar pains due to deficiency of kidney-yin.

Western Medicine diagnosis:

1. Pains over her lumbar part were 12 years, accompanied by numbness over her left lower limb for 2 months.

2. X-ray examination showed lumbar degenerative diseases.

First Diagnosis:

TCM: Lumbar pains.

Symptom identification: the deficiency of kidney-yin.  

Western medicine diagnosis: 1. lumbar degenerative diseases

                        2. Chronic gastritis

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ care.

3. Common diet.

4. Pathogenesis: the deficiency of kidney-yin.

5. TCM strategy: tonifying kidney-yin and nourishing bones and muscles, promoting the circulation of blood and freeing the channels as well as 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: Jan. 9, 2013                                             Time: 10:30 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient said pains over her lumbar part and there were numbness and pains over her left lower limb. When pains happened over her left lower limb, there was heat over there. She suffered tinnitus, bitterness in her mouth, and occasional abdominal distension, hiccup, and nausea. There was noisy sound over her gastral cavity. Her spirit, sleep and appetite were good. Urination and bowel movement were normal. BP: 120/80 mmHg. There were pressing pains on her lumbosacral portion, left-side buttock and left-side of her left lower limb. From the view of TCM, Dr. Ming thought that the case of the patient could be diagnosed as lumbar pains, due to the stasis of qi and blood as well as deficiency of kidney-yin. The treatment strategy for it would be to tonify kidney-yin and nourish bones and muscles, promote the circulation of blood and free the channels as well as relieve pains.

Date: Jan. 10, 2013                                             Time: 10:30 a.m.

The patient said pains over her left-side back were reduced somewhat. Bitter feeling in her mouth was less. Other conditions were the same. Feedback of her examination: stool routine: OB+-; Blood routine: urination, the functions of liver and kidney, blood sugar and blood fat were normal. X-ray over her back: Hyperosteogeny on her L2-L5 of lumbar vertebra.

Date: Jan. 11, 2013                                             Time: 10:30 a.m.

The patient said umbar pains and numbness of her left lower limb were reduced. There was no more bitterness in her mouth. She still felt occasional discomfort over her stomach. She had no palpitations, chest depression, nausea or vomiting.

Date: Jan. 15, 2013                                             Time: 10:30 a.m.

The patient felt further improvement in her lumbar pains. There was no other discomfort. Her tongue was red, with thin and yellowish tongue coating. Her pulse was weak and thready.  There were two pressing-pain points over her right-side back.

Date: Jan. 18, 2013                                             Time: 10:30 a.m.

The patient said her back pains were reduced. Her tongue was red, with thin and yellowish tongue coating. Her pulse was weak and thready.

Date: Jan. 22, 2013                                             Time: 10:00 a.m.

The patient said back pains were almost gone. There were slightly pains when bended backwards. Other conditions were turning better.

Date: Jan. 24, 2013                                             Time: 10:00 a.m.

The patient said, there were almost no more pains over her lower back. Her spirit, appetite and sleep were good. Her urination and bowel movement were normal. She decided to leave our hospital today.

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.