Brief
Summary:
On December 10, 2010,
Seddiqa, from Bahrain, who had been suffering lumbar pains for 3
years, developed into numbness and pains over her left lower
limb for 1 year, was hospitalized in our hospital. She achieved
some great improvement after 58 days TCM treatment.
Record of
Hospitalization
Name:
Seddiqa Sex: Female
Age:
48 Marital
Status: Unmarried
Nationality:
Bahraini
Date of Admission: Dec. 10,
2010
Companion:
Her Mother
First
Medical Record
Date:
Dec. 10, 2010 Time: 9:30 am
This 48-year-old lady
had been suffering from lumbar pains for 3 years, developed into
numbness and pains over her left lower limb for 1 year. The
patient was hospitalized in our hospital for TCM treatment at
19:40 pm on December 10, 2010.
Essential for Diagnosis:
1. The patient had been
suffering from pains over her lumbosacral portion for 3 years,
developed into numbness and pains over her left lower limb for 1
year.
2. The patient
complained of lumber pains due to work long time on the desk,
and at that time she did not pay much attention to that problem.
3 years ago, pains over her lumbar became severe, and then she
went to the Capital hospital of Thailand for examinations. The
MRI report presented that there was progressive lesion on L3-S1
and ring shaped defects on L3-L5. In the left side of L5-S1,
there was compression of the dura mater of spinal cord and the
left nerve roots. At that time, the diagnosis from the hospital
was lumbar intervertebral disc protrusion. The doctor gave her
some pain-killers, but the effects were not so perfect. 13 years
ago, because of abdominal pains, she went to the hospital for
examinations, which presented that there were five fibroids of
different sizes in her womb. She took the operation on these
fibroids. But 4 years ago, the fibroids occurred again, and the
largest one was 3.2*2.1*3.7cm. There was cyst in the right side
of her ovary, with the size of 8.2*4*4.2cm. At present, she did
not take any treatment for her fibroids.
3. When Seddiqa came to
our hospital, she suffered from evident pressing-pains over her
lumbosacral portion and her left-side buttock. There were pains
and stiffness over her left lower limb. There were evident
pressing-pains and rebound tenderness over her abdomen. She had
entered menopause for 3 years. She had night sweating and
paroxysmal fever. Her appetite and sleep were normal. Her spirit
was good. Her tongue was dark with yellow tongue coating. The
root of her tongue was a little bit bristle, with cracks along
both sides of her tongue body. Her pulse was weak. Bowel
movement and urination were normal.
4. T: 36.3＜C R: 20
times/minute P: 56 times/minute BP: 108/62mmHg
5. The patient was of
chronic and sick complexion with painful facial expression. She
grew normally with standard body shape. Her spirit activity was
normal. She had no difficulty to walk, but there were pains over
her left lower limb when she was walking.
6. The size and
formation of her thorax were normal. No enlargement with her
heart. Rhythm of her heart was 56 times per minute. Heart rate
was regular with no murmurs. Sound of
breathing in the lungs was clear, without any rhonchi.
7. MRI of June
19, 2010, showed that she had been suffering from
lumbar intervertebral
disc protrusion.
Diagnostic Basis:
TCM:
The patient had suffered from lumbosacral pains for three years,
accompanied by numbness and pains over her left lower limb and
left-side buttock. There were evident pressing-pains over her
abdomen. From the view of TCM, when the channels are obstructed,
there would be pains, and therefore, the qi and blood in the
body will be damaged. In addition, if people are sick for too
long, there would appear more deficiency and more stasis. So,
from this point of view, her tongue was dark with yellow tongue
coating. The root of her tongue was a little bit bristle, with
cracks along both sides of her tongue body. Her pulse was weak.
Therefore, her conditions could be diagnosed as Bi impediment.
Western Medicine:
There were pains and numbness over her lumbosacral portion and
left-side lower limb. And according to her MRI report, her
condition could be diagnosed as prolapse of lumbar
intervertebral disc.
Diagnostic
Differentiation:
TCM:
Bi impediment is usually differentiated from wilting pattern.
Wilting pattern may have the symptom of atrophy and weakness of
muscles, with no joint pains. So, it is easy to differentiate
them.
Western Medicine
diagnosis:
Her condition should be differentiated with
apoplectic sequela. Apoplectic sequela has the main symptom
of motion limitation of the limbs on one side of the body. Limbs
of the patient are weak, with no pains at the early stage of the
disease. Therefore, there is no difficulty to differentiate
them.
First Diagnosis:
TCM: Bi impediment and
Carbuncle.
Symptom identification:
the stasis of qi and blood as well as the blockage of
channels and network channels.
Western medicine
diagnosis: Prolapse of lumbar intervertebral disc.
Treatment strategy and
nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade
Å
care.
3. Common diet.
4. Pathogenesis: the
stasis of qi and blood as well as the blockage of channels and
network channels.
5. TCM strategy:
promoting blood circulation and removing blood stasis as well as
freeing the channels and relieving pains.
6. Herbal tea: one
dosage a day and drink twice
7. Acupuncture and
massage: once a day
8. Have more medical
examination if necessary.
Date: Dec. 11,
2010 Time: 9:00 am
Professor Zhang Xiukui
paid a visit to the patient. The patient complained of evident
pressing-pains over her lumbosacral part and her left buttock.
Her left lower limb was numb and painful. Pressing-pains over
her left knee were obvious. Evident pressing-pains and rebound
pains also appeared on her abdomen and lower legs. She had
entered menopause for 3 years. She had night sweating and
paroxysmal fever. Her appetite and sleep were normal. Her spirit
was good. Her tongue was dark with yellow tongue coating. The
root of her tongue was a little bit bristle, with cracks along
both sides of her tongue body. Bowel movement and urination were
normal. Her pulse was weak. From the view of TCM, professor
Zhang thought that the case of the patient could be diagnosed as
Bi impediment, due to the stasis of qi and blood as well as the
blockage of channels and network channels. The treatment
strategy for it would be to promote blood circulation and remove
blood stasis as well as free the channels and relieve pains.
Date: Dec. 12,
2010 Time: 10:00 am
The patient said there
were pains over her both shoulders. Physical check: BP:
110/70mmHg. Her heart rate was slow with regular heart rhythm of
58 times per minute. Pressing pains on the middle parts of her
shoulders were evident.
Date: Dec. 14,
2010 Time: 10:00 am
The patient said
pains over her shoulders were reduced a lot. There was no
evident improvement in her lumbosacral pains and pains over her
left lower limb.
Paroxysmal fever, night
sweating and dry taste in her mouth improved a little bit. Sleep
was not good. Her spirit was ok. Her tongue was dark with yellow
tongue coating. Root of her tongue was a little bristle. There
were cracks along both sides of her tongue body. Her pulse was
thready and weak.
Date: Dec. 20,
2010 Time: 10:00 am
The patient felt further
improvement in her shoulder pains. There still was no evident
improvement in her lumbosacral pains and pains over her left
lower limb. Paroxysmal fever, night sweating and dry taste in
her mouth improved a little bit. Pressing pains over her abdomen
were relieved. Her tongue was dark red with yellow tongue
coating. The side of her tongue was dry with cracks. Her pulse
was thready and weak.
Date: Dec. 24,
2010 Time: 10:00 am
The above mentioned
conditions were improved better a little bit.
Date: Dec. 28,
2010 Time: 10:00 am
The patient complained
of no evident improvement in her lumbosacral pains, but it was
better than before she came to our hospital. Night sweating and
paroxysmal fever further improved. There were still pains over
her legs, but better than before. Her tongue was red with thin
and yellow tongue coating. Tongue cracks were reduced. Her pulse
was thready and weak.
Date: Dec. 31,
2010 Time: 9:30 am
The patient said pains
over her lumbosacral part, left lower limb and her abdomen were
reduced a lot. Dryness in her mouth, sweating and paroxysmal
fever still existed. Pains over her shoulders almost dispelled.
Her tongue was red with yellow tongue coating. Her pulse was
thready and weak. Heart rate was 64 times/minute.
Date: Jan. 4,
2011 Time: 10:00 am
The patient said her
conditions kept improving better. Her tongue was red with yellow
tongue coating. Her pulse was thready and weak.
Date: Jan. 8,
2010 Time: 11:00 am
Professor Zhang paid a
visit to the patient this morning. The patient said pains over
lumbosacral part and her left lower limb were reduced a lot. In
recent days, dryness in her mouth, sweating and paroxysmal fever
improved obviously. Pains over her abdomen were reduced. Her
tongue was red with yellow tongue coating. There were tongue
cracks. Her pulse was thready and weak.
Date: Jan. 12,
2011 Time: 10:00 am
The patient said her
lumbar pains were reduced much. There were migratory pains over
the outer side of her left lower limb. Dryness in her mouth,
night sweating and paroxysmal fever kept changing better.
Discontinuous pains appeared on her abdomen. Today¨s MRI
presented that there was a fibroid with size of 3*2cm on the
uterine wall. The cyst in the right side of her ovary was 5*3.8
cm. After TCM treatment for one month, there was no big change
in the size of the fibroid, but the size of the cyst in the
right side of her ovary was shrinking. Her tongue was red with
thin and yellow tongue coating. There were tongue cracks. Her
pulse was thready and weak.
Date: Jan. 16,
2011 Time: 10:00 am
The patient said
pains over her left lower limb sometimes were less, and
sometimes were more.
Other conditions kept
changing better.
Date: Jan. 20,
2011 Time: 10:00 am
Pains over lumbosacral
part and left lower limb were reduced. Night sweating and
paroxysmal fever improved. The frequency of her abdominal pains
became lower. In the recent days, the patient had a sense of
scary when slept at the night.
Date: Jan. 24,
2011 Time: 10:00 am
The patient said the
abovementioned conditions improved. Her sense of scary during
her sleeps was reduced.
Date: Jan. 28,
2011 Time: 10:00 am
The patient said pains
over her left lower limb sometimes were less, and sometimes were
more. Recently, she did not suffer abdominal pains. Night
sweating and paroxysmal fever were not severe.
Date: Jan. 31,
2011 Time: 10:00 am
The patient said her
conditions changed better recently.
Date: Feb. 5,
2011 Time: 10:30 am
The patient said her
conditions were stable these days.
Date: Feb. 6,
2011 Time: 10:30 am
Seddiqa decided to leave
the hospital today. After nearly 2 months TCM treatment here in
our hospital, she achieved some improvement in her conditions.
Pains over her lumbosacral part and her left lower limb were
reduced. Pressing pains and rebound pains over her abdomen were
almost cured. Paroxysmal fever, night sweating and dry taste in
her mouth were improved a lot. The MRI report of January 12,
2011 presented that the largest fibroid now was 3*2cm with clear
edge lines. The cyst in the right side of her ovary was 5*3.8 cm
now. Its size shrank evidently.
Doctor¨s advice after
leaving hospital:
1. Avoid wind-cold,
maintain good moods, and take care of the diet.
2. Take herbal medicine
back for continuing treatment.
3. Keep
doing exercises.
