Patient Information
Name: Emily (pseudonym)
Gender: Female
Age: 55 years
Date of First Consultation: April 26, 2025
Chief Complaint
Lower back pain with numbness and pain in both lower limbs for over 3 years, worsened with insomnia in the last 6 months.
Present Illness
Chronic lower back pain, worsened by exertion, with numbness and tingling in both lower limbs. Symptoms worsened in the last 6 months, affecting sleep. Blood pressure fluctuates to 160/95 mmHg, requiring medication. Difficulty sleeping, frequent waking, vivid dreams, irritability, with little relief from analgesics.
Past Medical History
5-year history of hypertension, controlled. Denies diabetes or heart disease.
Initial Impression
Walks slowly, holding back, speaks weakly. Reports poor sleep and irritability.
Diagnosis
Root: Liver and Kidney Deficiency
Branch: Cold-Dampness Obstructing Meridians, Qi and Blood Stagnation
Treatment
Tonify Liver and Kidney, unblock meridians, expel wind and dampness, relieve pain, calm the mind.
Formula: Du Huo Ji Sheng Tang with modifications.
Lifestyle Recommendations
Avoid cold, keep warm; moderate exercise; Tai Chi/Qi Gong; soak feet before bed.
Expected Effect
7-10 days: Reduced pain and numbness, improved sleep.
2-4 weeks: Better pain, numbness, sleep; stable blood pressure.
3 months: Improved circulation, back, and leg function.
