Brief Summary: On March 22, 2015, Ms. Pan Juying, from Zhongfang County, who had been suffering repeated pains over her shoulder joints for more than ten years, being severe for half a month, was hospitalized in our hospital. Her condition got great improvement after 14 days TCM treatment with the help of Acupuncture, Herbal tea and Tuina in our hospital.

Record of Hospitalization

Name: Ms. Pan Juying                     Sex: Female

Age: 64                                            Marital Status: Married

Nationality: China                           Date of Admission: March 22, 2015

Companion: Alone

First Medical Record

Date: March 22, 2015              Time: 12:00 a.m.

This 64-year-old woman had been suffering from repeated pains over shoulder joints for more than ten years, and being severe for half a month. The patient was hospitalized in our hospital for TCM treatment at 12:00 a.m. on March 22, 2015.

Essential for Diagnosis:

1. The patient had been suffering from repeated pains over shoulder joints for more than ten years, and being severe for half month. She suffered from lumbago for more than ten years as well. She had lumbar sprain history in the year of 1979. She had no allergy history of any medicine or any food.

2. When the patient came to our hospital, she suffered joint-pains over her shoulders, and she could not lift up her arms. It was limited to stretch her arms towards her back. Sometimes she felt numb over her upper limbs, and her fingers were chilly. There was numbness and pains over her right lower limb. She could not walk or sit for a long time. If sitting for a long time, she felt tired. She felt sore over her knee-joints, while it does not relate with the weather changes. Appetite was good. Sleep was normal. Urination and bowel movement were normal.

3. T: 36.8°C   R: 18 times/minute    P: 66 times/minute     BP: 130/70mmHg

4. The patient grew normally. She was alert and cooperative. She had chronic sick facial complexion. There was no sign of yellow sclera or yellowish skin. There was no enlargement on the superficial lymph node of her whole body. Her neck was soft without resistant. She could turn her neck flexibly. There were obvious pains around her shoulder joints and elbow joints. The movement of lifting her upper limbs was slightly limited. It was better to stretch her left arm towards her back than to stretch her right arm. Her windpipe appearance was good and in the center. There was no distention of jugular vein. There was no enlargement on her thyroid gland. Rhythm of her heart was 66 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. We did not hear any pathologic sound. Her abdomen was soft with no pressing pains, rebound tenderness and enclosed mass. There were slight pressing pains over her S4, S5. Elevation test of straight right leg (+), Bragard Test (+). No pathological neuropathic positive. Her tongue was slightly red. Her tongue coating was thin and white. Her pulse was deep and unsmooth.

Diagnostic Differentiation:

TCM: 1. Shoulder Impediment

          2. Lumbargo