April 12, 2013, Yang Changpo, from the village of Yuanjia

On April 12, 2013, Yang Changpo, from the village of Yuanjia, who had been suffering lumbar pains for moe than one year, was hospitalized in our hospital. Her condition became severe in the recent two months. She achieved great improvement only after nearly 10 days TCM treatment with the help of Acupuncture, Herbal tea and Tuina in our hospital.

Record of Hospitalization

Name: Yang Changpo                                                                                           Sex: Female

Age: 40                                                                                                                 Marital Status: Married

Nationality: China                                                                                                 Date of Admission: Apr. 12, 2013

Companion: Alone

First Medical Record

Date: April. 12, 2013                                Time: 11:00 a.m.

This 40-year-old woman had been suffering lumbar pains for moe than one year. Her condition became severe for 2 months. The patient was hospitalized in our hospital for TCM treatment at 11:00 a.m. on April 12, 2013.

Essential for Diagnosis:

1. The patient had been suffering lumbar pains for more than one year. Her condition became severe in the recent 2 months. She was hospitalized in our hospital as a patient due to prolapse of lumbar intervertebral disc.

2. The patient complained that one year ago, she sprained her lumbar part during work, and then she suffered pains over her lumbar part. She went to the No. 3 People’s Hospital for CT examination, and the result was prolapse of lumbar intervertebral disc. She did not take any treatment, and the doctor only advised her to stay on bed for rest. While in the recent 2 months, she felt severe pains over her lumbar part, and she could not even for any labor work. In order to seek help from the TCM treatment, she came to our hospital.

3. When Ms. Yang came to our hospital, she suffered severe pains over her back. She could not bend or lift her back. She could not sit, lie, walk and stand for a long time. When she did some work, she felt much more pains, and when she got rest, the pains were relieved. Her pains were not related with the changes of weather. Her urination and bowel movement were normal. There were no pains and numbness over her lower limbs.

4. T: 37.1°C   R: 24 times/minute    P: 66 times/minute   BP: 110/74 mmHg

5. The patient grew normally with standard body shape. She was alert and cooperative. She had chronic sick facial complexion. There were no sign of yellow sclera or yellowish skin. There was no enlargement on the superfacial lymph node of her whole body. Facial features were normal. There was no enlargement on his thyroid gland. Rhythm of his heart was 66 times per minute. Heart rate was regular with on murmurs. Sound of breathing in the lungs was clear, without any rhonchi. There were obvious pressing pains over her fourth and fifth lumbar vertebras. There was no numbness over her lower limbs. There was light limitation on the movement of bending and lifting her back. Her urination and bowel movement were normal. Her tongue was red with yellowish tongue coatings. Her pulse was thready and wiry.

Diagnostic Differentiation:

TCM:

The patient complained that one year ago, she sprained her waist during works. Pains over her waist became severe day by day. Though she bought medicines to reduce pains, but the effects were not good. Long time of disease damaged the qi and blood in her body, and the cold-pathogen intruded into her spinal column. Therefore, she could not sit, lie, walk or stand for a long time, and pains became severe when she did some work. Her tongue was red with yellowish tongue coating. Her pulse was wiry, thready and unsmooth. According to the theory of TCM, her symptom could be diagnosed as lumbar pain, which was due to the deficiency of qi and blood and the stagnation of coldness on the spinal column. Treatment strategy should be warming and tonifying the kidney-yang, as well as promoting the flow of qi and blood.

Western Medicine diagnosis:

1. Sprained waist for more than one year.

2. Pressing pains were obvious on her fourth and fifth lumbar vertebras.

3. X-ray examination showed lumbar intervertebral disc protrusion.

First Diagnosis:

TCM: Lumbar pain.

Symptom identification: the deficiency of qi and blood and the stagnation of coldness on the spinal column

Western medicine diagnosis: Prolapse of lumbar intervertebral disc.

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ care.

3. Common diet.

4. Pathogenesis: the deficiency of qi and blood and the stagnation of coldness on the spinal column.

5. TCM strategy: warming and tonifying the kidney-yang, as well as promoting the flow of qi and blood.

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: Apr. 13, 2013                                            Time: 09:30 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient complained that one year ago, she sprained her waist during works. Pains over her waist became severe day by day. Though she bought medicines to reduce pains, but the effects were not good. She felt numbness over her lower limbs. Body Check: T: 37.1°C  R: 24 times/minute  P: 66times/minute  BP: 110/74mmHg. The patient grew normally with standard body shape. She was alert and cooperative. She had chronic sick facial complexion. There were no sign of yellow sclera or yellowish skin. There was no enlargement on the superficial lymph node of her whole body. Facial features were normal. There was no enlargement on his thyroid gland. Rhythm of his heart was 66 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. There were obvious pressing pains over her fourth and fifth lumbar vertebras. There was no numbness over her lower limbs. There was light limitation on the movement of bending and lifting her back. Her tongue was red with yellowish tongue coating. Her pulse was wiry, thready and unsmooth.

From the view of TCM, Dr. Ming thought that the case of the patient could be diagnosed as lumbar pains, due to the deficiency of qi and blood and the stagnation of coldness on the spinal column. The treatment strategy for it would be to warm and tonify the kidney-yang, as well as to promote the flow of qi and blood.

Date: Apr. 14, 2013                                            Time: 09:30 a.m.

The patient said lumbar pains were reduced slightly. The movement of bending and lifting her back was improved. There was no other obvious discomfort. Her tongue was red with yellowish tongue coating. Her pulse was wiry.

Date: Apr. 17, 2013                                            Time: 14:00 a.m.

The patient said lumbar pains were reduced obviously. Her pulse was wiry and slow.

Date: Apr. 19, 2013                                            Time: 10:00 a.m.

The patient said after these day TCM treatment, lumbar pains were completely gone. She could bend and lift her back flexibly. Vital signs of the patient were stable. Her pulse was wiry and slow.

Date: Apr. 20, 2013                                            Time: 09:30 a.m.

When paid visit to the patient, the patient said lumber pains were completely gone. She could bend and lift her back freely. Vital signs of the patient were stable. There were no more pressing pains over her fourth and fifth lumbar vertebras. Functions were normal. Her tongue was red. Her pulse was wiry and slow. The patient decided to leave our hospital today.

Doctor’s advice after leaving hospital:

1. Take enough rest, and avoid injury from work.

2. Take herbal medicine back for continuing treatment.

3. Pay attention to the diet. Avoid potato, beef meat, bamboo shoots and fern brake.