Brief Summary:
On June 15, 2014, Suping
Yang, came from the countryside near our hospital,, who had been
suffering from damp-heat impediment syndrome, back pains and
diabetes. He was hospitalized in our hospital. He achieved great
improvement after 16 days TCM treatment.
Record of
Hospitalization
Name:
Suping Yang Sex: Male
Age:
50 Marital Status: Married
Nationality:
China
Date of Admission: Jun. 15, 2014
Companion:
His wife
First Medical Record
Date:
June 15, 2014 Time: 14:30
p.m.
This 50-year-old man had
been suffering from right hip joint sore pains, accompanied with
limited movement for 3 days. The patient was hospitalized in our
hospital for TCM treatment at 14:30 p.m. on June 15, 2014.
Essential for Diagnosis:
1. The patient had been
suffering right hip joint sore pains, accompanied with limited
movement for 3 days. It was acute disease duration and acute
onset. There were no food and medicine for him to get allergy
response.
2. The patient suffered
pains over his right hip joint and his thigh, especial in the
medial edge of his thigh. He cannot walk and stand for a long
time. And the pains were related to the weather. He had dry
mouth and bitter mouth. He preferred cold drinks. His appetite
was poor. And his sleep was also not good. Sometimes the
lumbosacral portion had oppressive pains. The pitch activity was
slightly limited. There were no dizziness, palpitations and
short breath. The color of urine was dark yellow. And his bowel
movement was not good.
3. T: 37.2＜C R: 20
times/minute P: 78 times/minute BP: 110/70mmHg
The patient had normal
growth, physique and spiritual activity, while with actue
disease face. He cooperated with doctors when the physical
examination was made. There is no yellow skin or yellow sclera
over his whole body. There was no enlargement over his
superficial lymph node. His neck was soft without resistance.
There was no obvious hyperaemia in his throat. There was no
enlargement of tonsil. His trachea was symmetrical. The jugular
vein was of no engorgement. The thyroid was not swelling. His
chest was also symmetrical. Sound of breathing in the lungs was
clear, without any rhonchi. Rhythm of his heart was 78 times per
minute. Heart rate was regular without murmurs. His abdomen was
soft without pressing pains and rebound tenderness. There was no
obvious sign of deformity over his spine. There were slight
pressing pains over his 4th to 5th lumbar
vertebra and his 1st sacral vertebra. There were
obvious pressing pains over his right hip joints and his thigh,
near the inguen. And there was slight swelling at local field.
The straight leg raising test was limited. There were no nerve
pathological reflections. The tongue was red with yellow and
thick coating. The pulse was string-like, slippery and rapid.
4. Examination:
The result of MR showed that there was some effusion in his
right hip-joint cavity, the doctor diagnosed he should have
periostitis. The CT showed that L4/5 intervertebral disc
protrusion.
Diagnostic Basis:
TCM:
Damp-heat impediment syndrome
Western Medicine
diagnosis:
1.
Periostitis
over his right
hip-joint.
2.
Prolapse of lumbar
intervertebral disc.
3.
II type diabetes.
Treatment
strategy and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. GradeÅcare,
companion, low fat and salt diet.
3. Complete the related
examination, three routine inspection,
ESR examination, rheumatoid
factors, anti-O, the function of kidneys and liver and blood
sugar.
4. Herbal tea: one
dosage a day and drink twice
5. Acupuncture and
massage: once a day
6. Avoid wind and cold,
have a good mood and take care of diet.
Date: June 16,
2014 Time: 9:00 a.m.
This morning, DR. Ming
paid a visit to the patient. He complained of the pains over his
right hip joint, sore pains, accompanied with limited movement
for 3 days. He was hospitalized in our
hospital on June 15, 2014. He cannot
sit and stand for a long time. And the pains were related to the
weather. He had dry and bitter mouth. He preferred cold drinks.
His appetite was poor. And his sleep was also not good.
Sometimes the lumbosacral portion had oppressive pains. The
pitch activity was slightly limited. The color of urine was dark
yellow. And his bowel movement was not good. Body checked up: T:
37.2＜C R: 20 times/minute P: 78 times/minute BP:
110/70mmHg. He cooperated with doctors when the physical
examination was made. He had acute disease face. There is no
yellow skin or yellow sclera over his whole body. There was no
enlargement over his superficial lymph node. His neck was soft
without resistance. There were slight pressing pains over his 4th
to 5th lumbAr vertebra and his 1st sacral
vertebra. There were obvious pressing pains over his right hip
joints and his thigh, near the inguen. And there was slight
swelling at local field. The straight leg raising test was
limited. The tongue was red with yellow and thick coating. The
pulse was string-like and rapid.
Date: June 17,
2014 Time: 9:00 a.m.
The vital signs of the
patient were stable. The patient said there are sore pains over
his right hip joint and thight. But the pains were relieved
compared with the last two days. He still cannot walk and stand
for a long time. And movement was limited slightly. His spirit
was better. His appetite was good. His dry mouth and bitter
mouth were better. The color of urine was changed to slight
yellow. And his bowel movement was good. The pulse was string
and rapid, but not slippery.
Feedback of examination:
Glucose: 3.47 mmol/L, K: 3.44 mmol/L, Na: 117 mmol/L, CL: 78.9
mmol/L.
Date: June 20,
2014 Time: 9:00 a.m.
This morning the patient
had good spirit. He said the pains over his right hip-joint were
obviously improved. And movement is much more flexible than last
several days. He can walk for much more time. The dry and bitter
mouth disappeared. His appetite was normal. The tongue was red
with thin and yellow coating. The pulse was string-like, but not
rapid.
Date: June 23,
2014 Time: 9:00 a.m.
The vital signs of
patient were stable. The pains of his waist and hip-joint had
great improvement. And he can move flexible. Dry and bitter
mouth disappeared. Appetite was normal. There were no headache
and dizziness. The color of urine was slightly yellow. The bowel
movement was normal. The pulse was string-like and slow. He can
raise his leg much more flexiblely than before. His blood sugar
was 6.7. His condition was getting better.
Date: June 30,
2014 Time: 9:00 a.m.
The patient had good spirit. And the vital signs
of patient were stable. The patient said the pains over his
right hip-joint disappeared. He can move freely. There was no
any other discomfort. The patient decided to leave our hospital.
