Brief Summary: On Mar. 25, 2011, Tim, from Australia, who had suffered from impediment pattern or blockage syndrome and chronic diarrhea accompanied by stiff shoulders, sound of lumbar joints and weakness of the four limbs for at least 4 years, was hospitalized in our hospital. He had achieved great improvement after nearly 3 months TCM treatment.

Record of Hospitalization

Name: Tim                                                                     Sex: Male

Age: 36                                                                         Marital Status: Unmarried

Nationality: Australian                                                  Date of Admission: Mar. 25, 2011

Companion: Alone

　

First Medical Record

　

Date: Mar. 25, 2011 Time: 19:00

Tim, male, a 36-year-old, had suffered from impediment pattern and chronic diarrhea accompanied by stiff shoulders, sound of lumbar joints and weakness of the four limbs for at least 4 years. He was hospitalized in our hospital for treatment at 7 pm on Mar. 25, 2011.

　

Essential for Diagnosis:

1. The patient had suffered from shoulder stiffness, sound of the lumbar joints and weakness of the two lower limbs for four years.

2. During the last four years, the patient had been suffering from the shoulder stiffness, lumbar joints sound without any pains. It was hard for him to bend down and to stand up, meanwhile, the power of the two hands was less than normal people and the two hands were easy to be tired. When washing the hands, he had difficulties in pulling-up but not hard in pushing down. He also suffered from abdominal distension, while was worse after meals. When he walked a long distance, he would feel very fatigued, but when short distance, not so obvious. He often felt dry in the mouth, liking cold water. He did not feel cold on the hands and feet but often sweated during the day time.

3. In the year of 2010, he had been hospitalized once in our hospital because of the same disease.

4. T: 36.5＜C R: 20 times/minute P: 80 times/minute BP: 100/70mmHg

5. He grew normally with common nutrition and he was a little bit fat. His sense and speaking were normal. His mind was clear. His sense of balance was not so good when doing the standing-eyes-closed test.

6. Jugular vein, thorax, costa and the inter-costal muscles were normal. No irregularity with his breathing. Vocal tactile fremitus and cardiac sounds were normal. No cardiac murmurs. There were no pathological respiratory murmurs and rhonchi in the lungs. The rate of the pulse and heart were normal.

7. The abdomen was soft. The color of the skin was also normal. No enlargement of the liver and spleen. No abdominal tenderness, rebound tenderness and percussion tenderness over kidney region. There was sound on the vertebral joint when did movement.

8. The muscles of the four limbs were strong but the patient felt weak.

9. No bitter taste in the mouth. But he felt dry in the mouth and liked drinking cold water. The patient was easy to sweat during the daytime. No night urine, but the color of the urine was a little yellow.

10. The tongue was red with dry tongue coating. The pulse was a little wiry.

11. No irregularity on the neural system. Physiological curve radian of the lumbar vertebra was a little small. No swelling of the lymph gland.

　

Diagnostic Basis:

TCM: The patient had suffered from neck stiffness, movement sounds of the lumbar joints with the weak lower limbs. He often felt dry in the mouth and liked drinking cold water. No coldness on the hands and feet. Sweating often during the daytime. No sense of heat in the center of hands and feet. The urine was a little yellow. Tongue was red with dry tongue coating and the pulse was a little wiry. So, the main symptoms leaded to the diagnosis of lumbar strain or impediment pattern.

Western Medicine: The patient had suffered from neck stiffness, movement sounds of the lumbar joints but no pains. And when did heavy exercise, it became worse. There was no relevance to the weather, so the diagnosis was lumbar strain.

　

Diagnostic Differentiation:

TCM: The patient¨s disease should be differentiated from uarthritis. To the uarthritis, it is related to the Uric Acid (UA) accompanying with intense pains. The pains are getting worse when the UA is increasing. But this disease was caused by lumbar strain. So they are not difficult to be distinguished.

　

Western Medicine diagnosis: The patient¨s condition should be differentiated from ALS. ALS is caused by lesions of the central nervous system, accompanied by muscular atrophy and muscle jumping.

　

First Diagnosis:

TCM: impediment pattern

Symptom identification: qi vacuity, blood stagnation and heat-removing.

Western medicine diagnosis: lumbar strain

　

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Å care.

3. Common diet

4. TCM strategy: fortify the spleen and boost qi, soothe the channels and quicken the network vessels and strengthen the sinew and bones.

5. Herbal tea: one dosage a day and drink twice

6. Acupuncture and massage: once a day

7. Have more medical examination if necessary.

　

Date: Mar. 26, 2011 Time: 10:00 am

The patient had suffered from shoulder stiffness, lack of sense of balance, fatigue, inflexibility. It was hard to warm his body even under the sunlight. There were some pressing-pain points under his scapulae and sounds of the lumbar joints. The patient also felt weak of his lower limbs. Appetite was not good. He wanted to eat, but suffered abdominal distension after meals. Professor Yang and Dr. Ming believed that the symptoms of the patient were caused by muscular strain due to vacuity of the spleen, lung and qi, static blood obstruction on the vessels, and loss of channel qi. So the treatment of strategy was to fortify the spleen and boost qi, soothe the channels and quicken the network vessels and strengthen the sinew and bones. The prescription was as follows: danggui (Chinese angelica), honghua (carthamus), mugua (chaenomelis), etc. 6 dosages in total.

　

Date: Mar. 28, 2011 Time: 10:00 am

The patient had bowel movement for 4 times yesterday. There were no general pains over the body. No bitter taste in the mouth but still dry sense in the mouth. No change with the quantity of meal. Tongue coating was red and dry. He drank little water every day. The pulse was a little wiry.

　

Date: Mar. 31, 2011 Time: 10:00 am

The patient had bowel movement for 3 times yesterday. He felt a little bit tired, with red tongue coating and wiry pulse.

　

Date: Apr. 3, 2011 Time: 10:00 am

Sense of fatigue had been decreased. Abdominal distension had also been alleviated. Three times bowel movements yesterday.

　

Date: Apr. 6, 2011 Time: 10:00 am

The tight sense of the lumbar muscles was reduced. Three times of bowel movements yesterday.

Tongue coating was red and the pulse was wiry.

　

Date: Apr. 15, 2011 Time: 10:00 am

The patient felt much better about his lumbar problem and had better appetite. One time bowel movement yesterday and the stool had been shaped. Tongue coating was a little bit wetter than before.

　

Date: Apr. 18, 2011 Time: 10:00 am

The patient drank some wine yesterday. After that, he got 3 times bowel movement. So the doctor advised him not to drink wine any more. The stool was dry but not hard for him to defecate. There was some improvement on his shoulders and lumbar part. Tongue coating was white but not wet.

　

Date: Apr. 23, 2011 Time: 10:00 am

The patient had bowel movements two times yesterday, and the stool was not dry but soft. He felt much flexible than before with good sleep.

　

Date: Apr. 30, 2011 Time: 10:00 am

There was significant improvement in the sense of fatigue. Appetite was good. Not dry and bitter in the mouth. Tongue coating was a little pale. The pulse was normal but powerful.

　

Date: May 3, 2011 Time: 10:00 am

The patient had two times bowel movements. Appetite was normal. Tongue coating was pale and a little dry. The pulse was normal but powerful. He had no night urination.

　

Date: May 14, 2011 Time: 10:00 am

Good appetite and sleep. Two times bowel movements yesterday. No constipation. The urine was a little yellow. The doctor advised him to eat rice and not to eat potatoes.

　

Date: May 20, 2011 Time: 10:00 am

The patient had five times bowel movements yesterday, which was relevant to his cold. The pulse was floating. Not dry and bitter taste in the mouth.

　

Date: June 2, 2011 Time: 10:00 am

The stool was not so soft or hard. His spirit was good and appetite was normal. The pulse was normal, and the tongue coating was thin and moist.

　

Date: June 9, 2011 Time: 10:00 am

Recently, the patient had bowel movement once a day. Because he ate too spicy food the day before yesterday, he had bowel movements 3 times a day from the day before yesterday to yesterday.

　

Date: June 12, 2011 Time: 10:00 am

The patient caught cold recently, accompanied by heavy breathing sounds and coughing. Two times bowel movements everyday. He did not feel dry in the mouth. The pulse was floating and tongue coating was thin and pale.

　

Date: June 19, 2011

Today the patient had left the hospital. After nearly 3 months treatment, he achieved significant improvement to his condition. His shoulders were no longer stiff and the movement sounds on the lumbar joints had disappeared. His lower limbs became strong and powerful. Abdominal diarrhea had been improved, from 7 times a day to 2 times a day. The stool was soft.