Wallace, from USA, had been suffering from pains over his back and legs

Mr. Wallace, from USA, had been suffering from pains over his back and legs as well as edema over his lower legs for one and half years. He was hospitalized in our hospital on May 28, 2011 for TCM treatment. He achieved great improvement in his condition after nearly one month TCM treatment with the help of herbal tea, acupuncture, massage etc.

 

 Record of Hospitalization

Name: Wallace                                                                                                  Sex: Male

Age: 68                                                                                                             Marital Status: Married

Nationality: American                                                                                       Date of Admission: May 28, 2011

Companion: Alone

 

First Medical Record

Date: May. 28, 2011                                      Time: 14:00 pm

This 68-year-old gentleman had been suffering from pains over his back and legs as well as edema over his lower legs for one and half years. The patient was hospitalized in our hospital for TCM treatment on May 28, 2011.

 

Essential for Diagnosis:

1. The patient had been suffering from pains and numbness over his back and legs as well as edema over his lower legs for one and half years.

2. One and half years ago, the patient was attacked by rachitis, and after the treatment of surgery, he felt numb over his right face and both upper limbs, and at the same time, he had binocular diplopia, pains and numbness over his back and leg as well as edema over his both lower limbs. After taking treatment in his local hospital, numb feeling over his face and upper limbs, and binocular diplopia disappeared. Right now, he still suffered pains over his back and legs, and edema over his lower leg, especially over his left leg. He had walking problem with bad balance sensation. He also had chest depression, dizziness and headache. He sometimes suffered abdominal distension and burning pains over his stomach. Hearing of his both ears was going down and he needed to wear hearing-aids. He was easy to be tired and felt very weak over his whole general body. He felt dryness in his mouth with no bitterness, bad breath in his mouth. Color of his urine was slightly yellow and the volume was normal. Stool was brown but unshaped. Sleep was not good, but appetite was normal.

3. T: 36.2°C   R: 20 times/minute    P: 62 times/minute   BP: 125/80 mmHg

5. There were many red nevi and black wine spots in different sizes over his body, especially over his abdominal and chest parts. There was a 10cm surgery scar over his lumbar. He felt numb and painful over his buttocks. Several pressing-pain points existed over his lower legs, especially the insides. Both lower limbs were swelling. Telangiectasis and spider angioma were seen in his legs. He walked under the help of walkers. His tongue was pale with thin and white coating. The pulse was wiry and thready.

 

Diagnostic Basis and Differentiation:

TCM: The patient suffered from pains over his lumbar and leg, and pains and numbness over his buttocks. There were pressing pains over his lower limbs. Telangiectasis and spider angioma were evidently seen in his legs. Therefore, his condition could be diagnosed as Numbness syndrome and edema. Numbness syndrome should be differentiated with atrophy syndrome. Both syndromes show dyskinesia of the limbs, but the atrophy syndrome mainly manifests muscle atrophy and uselessness of the muscles. Edema should be differentiated with distension. Distension shows that the abdomen is swelling like a drum and the skin shows ochrodermia. Veins over the abdomen pop out. Therefore, it is easy to differentiate them.

 

First Diagnosis:

TCM: 1. Numbness syndrome           

      2. Edema                 

Western Medicine: Spondylitis postoperative

 

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade  care.

3. Common diet.

5. TCM strategy: to promote the circulation of qi and remove blood stagnation, as well as to disinhibit water and disperse swelling.

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

7. Acupuncture and massage: once a day.

 

Date: May. 29, 2011                                      Time: 10:00 pm

Dr. Ming paid a visit to the patient this morning. The patient complained that one and half years ago, the patient was attacked by rachitis, and after the treatment of surgery, he felt numb over his right face and both upper limbs, and at the same time, he had binocular diplopia, pains and numbness over his back and leg as well as edema over his both lower limbs. After taking treatment in his local hospital, numb feeling over his face and upper limbs, and binocular diplopia disappeared. Right now, he still suffered pains over his back and legs, and edema over his lower leg, especially over his left leg. He had walking problem with bad balance sensation. He also had chest depression, dizziness and headache. He sometimes suffered abdominal distension and burning pains over his stomach. Hearing of his both ears was going down and he needed to wear hearing-aids. He was easy to be tired and felt very weak over his whole general body. He felt dryness in his mouth with no bitterness bad breath in his mouth. Color of his urine was slightly yellow and the volume was normal. Stool was brown but unshaped. Sleep was not good, but appetite was normal. The tongue was pale with thin and white tongue coating. Dr. Ming thought from the principle of TCM that his condition should be Numbness syndrome and edema, which was due to qi stasis and blood stagnation as well as stasis blocking the water circulation. Therefore, the treatment should be to promote the circulation of qi and remove stagnation as well as to disinhibit the water and disperse swelling.

 

Date: May. 30, 2011                                      Time: 10:00 pm

The patient said she slept for 7 running hours. Other conditions were the same as above-mentioned.

 

Date: May. 31, 2011                                      Time: 10:00 pm

The patient said sleep was good. Pains and edema over his lower limbs were reduced a little bit, and his lower limbs could feel the heat and coldness.

 

Date: June. 1, 2011                                         Time: 10:00 pm

The patient said the pains, edema and numbness over his lower limbs were evidently better, while pains still existed on his back and buttocks.  

 

Date: June 4, 2011                                         Time10:00 am

Edema over the patient’s lower limbs was improved greatly, and the limbs recovered perception. The buttocks were still painful and numb.

 

Date: June 7, 2011                                         Time10:00 am

The patient complained that the herbal tea was too bitter for him to swallow it.

 

Date: June10, 2011                                         Time10:00 am

Swelling over his lower limbs was reduced a lot. There was no improvement in the pains and numbness over his back.

 

Date: June13, 2011                                         Time10:00 am

The patient said his back was still painful. He was about to vomit after supper last night.

 

Date: June16, 2011                                         Time10:00 am

Today, the patient said that pains and numb feeling over his back were reduced somewhat. But feet were swelling during the night in recent two days and in the second morning, swelling disappeared.

 

Date: June 20, 2011                                         Time10:00 am

Mr. Wallace said the region of his back pains was nearly a circle with the diameter of 15cm. Feet were swelling since 6 o’clock in the evening, and disappeared in the next morning. At present, walking balance was better. His tongue was dark with yellowish and greasy coating. His pulse was wiry.

 

Date: June24, 2011                                         Time10:00 am

After nearly one month TCM treatment in our hospital, now pains and edema over his back and legs were improved. Swelling over his two lower limbs was dispelled. Walking balance was much better. He could control his walking speed and also he could walk backwards by himself, even though he could not walk for a long time. Now, he suffered no chest depression, dizziness, and headache as well as spasm any more. The doctor advised him to avoid wind and cold, take care of the diet and keep good mood. In addition, he would take medicine back home continuing the treatment. The patient also needed to keep exercise.

Previous: 2011, Tim, from Australia, who had suffered from impediment pattern or blockage syndrome and chronic

Next: Mr. Bala, from Nigeria, had been suffering from diabetes