Brief Summary: On Jan. 01, 2015, Mr. Pan Yue, from the Zhongfang County near our hospital, who had been suffering from low back pains for 15 years. His condition became worse, accompanied with numbness over his left leg and pains for 4 days. He was hospitalized in our hospital. He achieved great improvement after 10 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization

Name: Pan Yue                            Sex: Male

Age: 43                                         Marital Status: Married

Nationality: China                        Date of Admission: March 30, 2013

Companion: Alone

First Medical Record

Date: Jan. 01, 2015                          Time: 11:00 a.m.

This 43-year-old man had been suffering from low back pains for 15 years, accompanied with numbness over his left leg. And his condition was getting worse, he had pains for 4 days. The patient was hospitalized in our hospital for TCM treatment at 9:00 a.m. on Jan. 01, 2015.

Essential for Diagnosis:

1. The patient said he started low back pains 15 years ago because of over work. The patient’s condition was aggravated. He had difficulties in walking and turning over his body. At that time he took the treatment, his symptoms disappeared. Yet he was admitted to the hospital many times in recent years because of attack of waist. In June, 2011, he took the examination at the No. 1 People Hospital in Huaihua. The X-ray examination showed L4/L5 herniated disk, L3 and L4 centrum hyperosteogeny. 4 days ago, because of overwork his low back pains relapsed, and accompanied with numbness and pains over his left leg. The patient wanted TCM treatment, so he came to our hospital. There was no food and medicine for him to get allergy response.   

2.  When Mr. Pan Yue came to our hospital, he had pains over his lumbosacral portion. When the doctor press his lumbosacral portion, the pains became very serious, especially the left side. And there were obvious numbness and pains over the left leg. It was difficulties to bend his waist and to walk. Turning over his body and standing or sitting kept the forced posture. His spirit was not good. His appetite and sleep were not good. His urination and bowel movement were normal.

3.  T: 36.3°C   R: 20 times/minute    P: 85 times/minute   BP: 130/80 mmHg

4. The patient had normal spiritual status and natural facial expression. He cooperated with doctors when the physical examinations were made. There was no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. His neck was soft. His trachea was symmetrical. There was no enlargement over his thyroid. The jugular vein was of no engorgement. His chest was symmetrical without deformity. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 85 times per minute. Heart rate was regular with no murmurs. His abdomen was soft with no pressing pains and rebound tenderness. There was no sign of deformity over his spine. The straight leg rising test showed that the result of his left leg was positive. The results of figure of “4” test were positive in his left side. There were no pathological reflections, but the physiological reflections existed. The tongue body was dark red with yellow and thin coating. The pulse was taut and slippery.

5. Auxiliary examinations: The X-ray examination showed L4/L5 herniated disk, L3 and L4 centrum hyperosteogeny.