June 15, 2014, Suping Yang, back pains and diabetes
On June 15, 2014, Suping Yang, came from the countryside near our hospital,, who had been suffering from damp-heat impediment syndrome, back pains and diabetes. He was hospitalized in our hospital. He achieved great improvement after 16 days TCM treatment.
Record of Hospitalization Name: Suping Yang Sex: Male Age: 50 Marital Status: Married Nationality: China Date of Admission: Jun. 15, 2014 Companion: His wife
First Medical Record
Date: June 15, 2014 Time: 14:30 p.m. This 50-year-old man had been suffering from right hip joint sore pains, accompanied with limited movement for 3 days. The patient was hospitalized in our hospital for TCM treatment at 14:30 p.m. on June 15, 2014. Essential for Diagnosis: 1. The patient had been suffering right hip joint sore pains, accompanied with limited movement for 3 days. It was acute disease duration and acute onset. There were no food and medicine for him to get allergy response. 2. The patient suffered pains over his right hip joint and his thigh, especial in the medial edge of his thigh. He cannot walk and stand for a long time. And the pains were related to the weather. He had dry mouth and bitter mouth. He preferred cold drinks. His appetite was poor. And his sleep was also not good. Sometimes the lumbosacral portion had oppressive pains. The pitch activity was slightly limited. There were no dizziness, palpitations and short breath. The color of urine was dark yellow. And his bowel movement was not good. 3. T: 37.2°C R: 20 times/minute P: 78 times/minute BP: 110/70mmHg The patient had normal growth, physique and spiritual activity, while with actue disease face. He cooperated with doctors when the physical examination was made. There is no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. His neck was soft without resistance. There was no obvious hyperaemia in his throat. There was no enlargement of tonsil. His trachea was symmetrical. The jugular vein was of no engorgement. The thyroid was not swelling. His chest was also symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 78 times per minute. Heart rate was regular without murmurs. His abdomen was soft without pressing pains and rebound tenderness. There was no obvious sign of deformity over his spine. There were slight pressing pains over his 4th to 5thlumbar vertebra and his 1st sacral vertebra. There were obvious pressing pains over his right hip joints and his thigh, near the inguen. And there was slight swelling at local field. The straight leg raising test was limited. There were no nerve pathological reflections. The tongue was red with yellow and thick coating. The pulse was string-like, slippery and rapid. 4. Examination: The result of MR showed that there was some effusion in his right hip-joint cavity, the doctor diagnosed he should have periostitis. The CT showed that L4/5 intervertebral disc protrusion. Diagnostic Basis:
TCM: Damp-heat impediment syndrome
Western Medicine diagnosis:
1. Periostitis over his right hip-joint.
2. Prolapse of lumbar intervertebral disc.
3. II type diabetes.
Treatment strategy and nursing:
1. Routine care of traditional Chinese internal medicine.
2. GradeⅡcare, companion, low fat and salt diet.
3. Complete the related examination, three routine inspection, ESR examination, rheumatoid factors, anti-O, the function of kidneys and liver and blood sugar.
4. Herbal tea: one dosage a day and drink twice
5. Acupuncture and massage: once a day 6. Avoid wind and cold, have a good mood and take care of diet.
Date: June 16, 2014 Time: 9:00 a.m.
This morning, DR. Ming paid a visit to the patient. He complained of the pains over his right hip joint, sore pains, accompanied with limited movement for 3 days. He was hospitalized in our hospital on June 15, 2014. He cannot sit and stand for a long time. And the pains were related to the weather. He had dry and bitter mouth. He preferred cold drinks. His appetite was poor. And his sleep was also not good. Sometimes the lumbosacral portion had oppressive pains. The pitch activity was slightly limited. The color of urine was dark yellow. And his bowel movement was not good. Body checked up: T: 37.2°C R: 20 times/minute P: 78 times/minute BP: 110/70mmHg. He cooperated with doctors when the physical examination was made. He had acute disease face. There is no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. His neck was soft without resistance. There were slight pressing pains over his 4th to 5th lumbAr vertebra and his 1st sacral vertebra. There were obvious pressing pains over his right hip joints and his thigh, near the inguen. And there was slight swelling at local field. The straight leg raising test was limited. The tongue was red with yellow and thick coating. The pulse was string-like and rapid.
Date: June 17, 2014 Time: 9:00 a.m. The vital signs of the patient were stable. The patient said there are sore pains over his right hip joint and thight. But the pains were relieved compared with the last two days. He still cannot walk and stand for a long time. And movement was limited slightly. His spirit was better. His appetite was good. His dry mouth and bitter mouth were better. The color of urine was changed to slight yellow. And his bowel movement was good. The pulse was string and rapid, but not slippery. Feedback of examination: Glucose: 3.47 mmol/L, K: 3.44 mmol/L, Na: 117 mmol/L, CL: 78.9 mmol/L.
Date: June 20, 2014 Time: 9:00 a.m.
This morning the patient had good spirit. He said the pains over his right hip-joint were obviously improved. And movement is much more flexible than last several days. He can walk for much more time. The dry and bitter mouth disappeared. His appetite was normal. The tongue was red with thin and yellow coating. The pulse was string-like, but not rapid.
Date: June 23, 2014 Time: 9:00 a.m.
The vital signs of patient were stable. The pains of his waist and hip-joint had great improvement. And he can move flexible. Dry and bitter mouth disappeared. Appetite was normal. There were no headache and dizziness. The color of urine was slightly yellow. The bowel movement was normal. The pulse was string-like and slow. He can raise his leg much more flexiblely than before. His blood sugar was 6.7. His condition was getting better.
Date: June 30, 2014 Time: 9:00 a.m.
The patient had good spirit. And the vital signs of patient were stable. The patient said the pains over his right hip-joint disappeared. He can move freely. There was no any other discomfort. The patient decided to leave our hospital.