Brief Summary: On March 25, 2015, Ms. Yuan Jun, from Zhongfang County, who had been suffering from lumbago and powerlessness for 12 years, being severe for 8 months, 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. Yuan Jun                  Sex: Female

Age: 50                                      Marital Status: Married

Nationality: China                     Date of Admission: March 25, 2015

Companion: Alone

First Medical Record

Date: March 25, 2015                   Time: 14:00 a.m.

This 50-year-old woman had been suffering from lumbago and powerlessness for 12 years, being severe for 8 months. The patient was hospitalized in our hospital as a patient with Prolapse of Lumbar Intervertebral Disc for TCM treatment at 09:00 a.m. on March 22, 2015.

Essential for Diagnosis:

1. The patient said 12 years ago she started to appear the pains over her low back because of her profession. She could not turn her body. She went to the Huaihua TCM Hospital to make a test. She was diagnosed with Prolapse of Lumbar Intervertebral Disc. She got the treatment with western medicine and TCM. Her condition was better. Yet in recent years, the lumbago repeated. In August of 2014, she had acute sever pains over her low back. She could not stand erectly and walk. It is difficult to turn over in bed. At that moment she got the treatment at Huaihua TCM Hospital, her condition improved. The patient want to the comprehensive TCM treatment, she came to our hospital for treatment. She had neuropathic insomnia history for 3 years and rheumatic arthritis for 7 years. She had no allergy history of any medicine or any food.

2. When the patient came to our hospital, she had following symptoms, such as dreaminess, insomnia and forgetfulness. And there was lumbago which lead her difficult to turn over. She had chilly limbs, weakness and pains over her knee-joints. And the pains were related with the changes of the weather. Whenever the weather was getting cold, the pains got worse. There were dizziness and headache. She had a poor spiritual status. Her appetite was good, and her urination and bowel movement were normal.

3. T: 36.5°C     R: 20 times/minute    P: 76 times/minute     BP: 140/80mmHg

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 and also no enlargement on the superficial lymph node of her whole body. Facial features were normal with masses. There were pressing pains over her top of her head and tempora bone. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. There was no enlargement over her superficial lymph node. Her neck was soft. Her trachea was symmetrical. There was no enlargement over her thyroid. The jugular vein was of no engorgement. Her chest was symmetrical without deformity. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of her heart was 76 times per minute. Heart rate was regular with no murmurs. Her abdomen was soft with no pressing pains and rebound tenderness. There was no sign of deformity over her spine. There were pressing pains over her muscle from L1 to L5, and as well as her knee joints. The meningeal irritation sign was negative. There were no pathological reflections, but the physiological reflections existed. The tongue body was light red with white and thin coating. The pulse was deep and slippery.