Brief Summary: Mr. Wallace, from USA, had been suffering from pains over his back and legs as well as edema over his lower legs for one and half years. He was hospitalized in our hospital on May 28, 2011 for TCM treatment. He achieved great improvement in his condition after nearly one month TCM treatment with the help of herbal tea, acupuncture, massage etc.

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Record of Hospitalization

Name: Wallace                                  Sex: Male

Age: 68                                              Marital Status: Married

Nationality: American                        Date of Admission: May 28, 2011

Companion: Alone

First Medical Record

Date: May. 28, 2011                                      Time: 14:00 pm

This 68-year-old gentleman had been suffering from pains over his back and legs as well as edema over his lower legs for one and half years. The patient was hospitalized in our hospital for TCM treatment on May 28, 2011.

Essential for Diagnosis:

1. The patient had been suffering from pains and numbness over his back and legs as well as edema over his lower legs for one and half years.

2. One and half years ago, the patient was attacked by rachitis, and after the treatment of surgery, he felt numb over his right face and both upper limbs, and at the same time, he had binocular diplopia, pains and numbness over his back and leg as well as edema over his both lower limbs. After taking treatment in his local hospital, numb feeling over his face and upper limbs, and binocular diplopia disappeared. Right now, he still suffered pains over his back and legs, and edema over his lower leg, especially over his left leg. He had walking problem with bad balance sensation. He also had chest depression, dizziness and headache. He sometimes suffered abdominal distension and burning pains over his stomach. Hearing of his both ears was going down and he needed to wear hearing-aids. He was easy to be tired and felt very weak over his whole general body. He felt dryness in his mouth with no bitterness, bad breath in his mouth. Color of his urine was slightly yellow and the volume was normal. Stool was brown but unshaped. Sleep was not good, but appetite was normal.

3. T: 36.2C   R: 20 times/minute    P: 62 times/minute   BP: 125/80 mmHg

5. There were many red nevi and black wine spots in different sizes over his body, especially over his abdominal and chest parts. There was a 10cm surgery scar over his lumbar. He felt numb and painful over his buttocks. Several pressing-pain points existed over his lower legs, especially the insides. Both lower limbs were swelling. Telangiectasis and spider angioma were seen in his legs. He walked under the help of walkers. His tongue was pale with thin and white coating. The pulse was wiry and thready.

Diagnostic Basis and Differentiation:

TCM: The patient suffered from pains over his lumbar and leg, and pains and numbness over his buttocks. There were pressing pains over his lower limbs. Telangiectasis and spider angioma were evidently seen in his legs. Therefore, his condition could be diagnosed as Numbness syndrome and edema. Numbness syndrome should be differentiated with atrophy syndrome. Both syndromes show dyskinesia of the limbs, but the atrophy syndrome mainly manifests muscle atrophy and uselessness of the muscles. Edema should be differentiated with distension. Distension shows that the abdomen is swelling like a drum and the skin shows ochrodermia. Veins over the abdomen pop out. Therefore, it is easy to differentiate them.