TCM China

TCM China:

Record of Herbal Treatment Of Zhang Li, from China Improvement Of Pain

 

 

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Brief Summary: On April 5, 2016, Ms. Zhang Li, from Zhongfang County, who had been suffering from repeated pain over her left hip for 10 years, being severe for 14 days. She was hospitalized in our hospital. Her condition got great improvement after 11 days TCM treatment with the help of Acupuncture, Herbal tea and Tuina in our hospital.

                                                                 Record of Hospitalization

Name: Ms. Zhang Li                                                       Sex: Female

Age: 38                                                                          Marital Status: Married

Nationality: China                                                          Date of Admission: April 5, 2016

Companion: Alone

               First Medical Record

Date: March 23, 2016                                    Time: 11:30 a.m.

This 38-year-old woman had been suffering from repeated pain over her left hip for 10 years, being severe for 14 days. The patient was hospitalized in our hospital as a patient with myofascitis for TCM treatment at 9:30 a.m. on April 5, 2016.

Essential for Diagnosis:

1. The patient said 10 years ago she had pain over her left hip since she was working at her desk for a long time and prolonged sitting. She took the painkiller to relief the pain. In recent years, the interval time of pain between each time was shorter and more frequent. And the pain often accompanied with numbness over her left lower limb. The patient came to our hospital for TCM treatment. There was medical history of periathritis of shoulder for 2 years and iron deficiency anemia. And she also had history of abnormal menstruation and cerebral arterial spasm.

2. When the patient came to our hospital, she suffered stabbing pain over her left hip, accompanied with numbness over her left lower limb, being severe when she moved her left leg. There was pain over her left shoulder joint, the activity was slightly limited. Occasionally she had headache and dry mouth. She was in good spirit. The appetite and sleeping were good. The urination was normal, the color of urine was slight yellow.

3. T: 36.5°C     R: 20 times/minute    P: 70 times/minute     BP: 100/60mmHg

4. The patient grew normally. She was alert and cooperative. She had chronic sick facial complexion. She walked slowly. 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 without masses and pressing pains. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. Her ears were normal without secreta and pressing pain. Her hearing was normal. Her neck was soft without resistance. There was no pain over her neck. There was no enlargement over her thyroid.The jugular vein was of no engorgement. Her windpipe appearance was good and in the center. Her chest was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of her heart was 70 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 was obvious pressing pains over her left shoulder and left hip. And there was numbness and pain over her left lower limb. The meningeal irritation sign was negative. There were no pathological reflections, but the physiological reflections existed. The tongue body wasdark red with thin coating. The pulse was wiry and weak.

Diagnostic Differentiation:

TCM: Impediment, Stagnation of qi and stasis of blood.

Western Medicine diagnosis:

1. myofascitis

2. periathritis of shoulder

3. iron deficiency anemia

4. cerebral arterial spasm

5. abnormal menstruation

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade  care, common diet, avoid spicy food.

3. Completed the related examination, three routine inspection, the function of the kidneys and the liver, HB 5 test, blood fat, blood sugar, anti-O, RF and IMX.

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

5. Acupuncture and massage: once a day.

6. Avoid wind-cold, regular daily life, have a good mood and take care of diet.

Date: April 06, 2016                                          Time: 10:00 a.m.

Dr. Luo, doctor-in-charge, paid a visit to the patient. The patient complained suffered stabbing pain over her left hip, accompanied with numbness over her left lower limb, being severe when she moved her left leg. There was pain over her left shoulder joint, the activity was slightly limited. Occasionally she had headache and dry mouth. She was in good spirit. The appetite and sleeping were good. The urination was normal, the color of urine was slight yellow. The bowel movement was normal. The tongue body wasdark red with thin coating. The pulse was wiry and weak. The tongue body wasdark red with thin coating. The pulse was wiry and weak.

Date: April 07, 2016                                          Time: 10:00 a.m.

The patient said the stabbing pain and numbness over her left hip and left lower limb slightly relieved. The pain over her left shoulder joint improved. The other symptoms was   almost the same. There was no obvious improvement. Taking the herbal tea to observe the effect.

Date: April 08, 2016                                          Time: 10:00 a.m.

The patient said the stabbing pain over her left hip and the numbness of her left lower limb obviously improved. Doctor adjusted the formula.

Date: April 10, 2016                                          Time: 10:00 a.m.

The patient said the stabbing pain over her left hip and the numbness of her left lower limb became better day by day. While she still had the pressing pain. The tongue body was rd with thin coating. Continued the formula.

Date: April 15, 2016                                          Time: 10:00 a.m.

The patient was in good spirit without the feeling of fatigue. the stabbing pain over her left hip and the numbness of her left lower limb almost disappeared. And the headache also disappeared. The patient decided to leave the hospital tomorrow. She took the herbal tea back to continue the treatment and consolidate the effect.