Brief Summary: On April 15, 2015, Mr. Shi Xianzhou, from Longjing village of Zhongfang County, who had been suffering repeated pains over his lumbar, companied by numbness over his left leg for more than ten years, and being severe for 3 months. He was hospitalized in our hospital. He achieved great improvement only after 16 days TCM treatment with the help of acupuncture, herbal tea and tuina in our hospital. 

Record of Hospitalization 

Name: Shi Xianzhou                       Sex: Male

Age: 60                                           Marital Status: Married

Nationality: China                          Date of Admission: Apr. 15, 2015

Companion: Alone 

First Medical Record 

Date: April 15, 2015                      Time: 10:30 a.m. 

This 60-year-old man had been suffering from pains over his lumbar for ten years, companied by numbness over his left leg for more than ten years, and being severe for 3 months. The patient was hospitalized in our hospital as a patient with Prolapse of Lumbar Intervertebral Disc for TCM treatment at 10:30 a.m. on April 15, 2015. 

Essential for Diagnosis: 

1.  The patient had been suffering repeated pains over his lumbar, and accompanied by numbness over his left leg for more than ten years. His condition became severe in recent 3 months. There was the history of lumbar sprain and orchitis surgery. There is no history of  allergic any medicine or any food. 

2.  When he came to our hospital, he suffered pains over his lumbar and his left skeletons spine joint, and accompanied by numbness over his left leg. And the numbness radiated to his feet. In recent 3 months, his condition was getting worse. He can’t walk, stand and sit for a long time. When he turned over his body in bed, the pains were severe. He felt cold, while his skin was hot. He also suffered occasional dizziness, yet without headache and tinnitus. Sometimes he had sweating. His appetite and sleeping were good. The urination and bowel movement were normal.

3. T: 36.8°C   R: 20 times/minute    P: 66 times/minute   BP: 140/70mmHg 

5. The patient grew normally with standard body shape. He was alert and cooperative. He had chronic sick facial complexion. He was in compulsive position. There was no sign of yellow sclera or yellowish skin and also no enlargement on the superficial lymph node of his whole body. His neck was soft without resistance. His trachea was symmetrical. Facial features were normal without masses. There was no enlargement over his thyroid. The jugular vein was of no engorgement. His chest was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 66 times per minute. His abdomen was soft with no pressing pains and rebound tenderness. There was no obvious swelling, yet with slight pressing pains. There was no sign of deformity over his spine. There was obvious pressing pains around his lumbar vertebra. Elevation test of straight left leg (+),Bragard Test (+).The meningeal irritation sign was negative. There were no pathological reflections, but the physiological reflections existed. His tongue was dark red with yellow tongue coatings. His pulse was string, deep and powerful.

Diagnostic Differentiation:

TCM: Lumbargo

Western Medicine diagnosis:

Prolapse of Lumbar Intervertebral Disc