Study of Traditional Chinese Medicine (TCM) Medical Records
Patient Info:
Name: James (Alias), Gender: Male, Age: 42
Occupation: Office Worker, Location: London, UK
Chief Complaint:
Chronic lower back pain (6+ months), worsens with sitting/exertion, relieved by rest. Dull ache, occasional stiffness.
History:
Gradual onset, no injury. Sedentary lifestyle. Worse in mornings/after sitting. OTC meds/stretching offer little relief.
Diagnosis:
腰肌劳损 (Lumbar Muscle Strain) – Kidney deficiency with Qi & Blood stagnation.
Treatment Plan:
1. Acupuncture: BL23, DU4, BL40, GB34, SP6, BL60. 2×/week, 4 weeks.
2. Herbal Medicine: Du Huo Ji Sheng Tang, decoction 2× daily.
3. Cupping: Bladder meridian, 1×/week.
4. Lifestyle: Stretching, breaks every 30–45 min, warm/nourishing diet.
Effect Summary:
2 Weeks: Pain reduced by 30%, improved morning stiffness, faster recovery.
4 Weeks: Pain reduced by 50%–60%, better daily function, stronger pulse.
6–8 Weeks: Pain nearly gone, increased endurance, no recurrence.
Conclusion:
TCM treatment (acupuncture, herbs, cupping, lifestyle changes) achieved 70%–90% pain relief with a low risk of recurrence.
