2024年4月10日发(作者：)

腰椎间盘突出中医门诊病历模板范文

英文回答：

Chief Complaint: Low back pain with radiating pain down

the leg for 3 months.

History of Present Illness: The patient, a 45-year-old

male, presents with complaints of low back pain that

started 3 months ago. The pain is described as a dull ache

in the lower back, which radiates down the right leg. The

pain is aggravated by prolonged sitting or standing and is

relieved by lying down. The patient also reports numbness

and tingling sensation in the right leg. There is no

history of trauma or injury.

Past Medical History: The patient has a history of

occasional low back pain, but this current episode is more

severe and persistent. There is no history of any other

significant medical conditions.

Physical Examination: On physical examination, the

patient has tenderness over the lower back and right

buttock region. Straight leg raise test is positive on the

right side, causing radiating pain down the leg. Motor

strength and reflexes are normal. Sensation is decreased in

the right leg.

Diagnosis: Lumbar disc herniation (L4-L5) based on the

patient's symptoms, physical examination findings, and

positive straight leg raise test.

Treatment Plan: The patient will be treated with a

combination of acupuncture and Chinese herbal medicine.

Acupuncture will be used to relieve pain and reduce

inflammation. Chinese herbal medicine will be prescribed to

strengthen the patient's Qi and nourish the Kidney and

Liver, which are believed to be involved in the

pathogenesis of lumbar disc herniation. The patient will

also be advised to avoid activities that exacerbate the

pain and to maintain proper posture.

Prognosis: With appropriate treatment and lifestyle

modifications, the patient's symptoms should improve

gradually over time. However, complete resolution of

symptoms may take several weeks to months.

中文回答：

主诉，腰痛并放射至腿部3个月。

现病史，患者为一名45岁的男性，主诉腰痛始于3个月前。疼

痛描述为下腰部隐痛，并向右腿放射。长时间坐立或站立会加重疼

痛，躺下可以缓解。患者还报告右腿有麻木和刺痛感。没有外伤或

受伤的历史。

既往病史，患者有偶尔的腰痛史，但这次症状更严重且持续。

没有其他重要的病史。

体格检查，体格检查发现患者在下腰部和右臀部区域有压痛。

右侧直腿抬高试验阳性，引起腿部放射痛。肌力和反射正常。右腿

感觉减退。

诊断，根据患者的症状、体格检查结果和直腿抬高试验阳性，

诊断为腰椎间盘突出（L4-L5）。

治疗计划，患者将接受针灸和中药治疗的结合。针灸将用于缓

解疼痛和减轻炎症。中药将被开方以增强患者的气血，并滋养肾脏

和肝脏，这被认为与腰椎间盘突出的发病机制有关。患者还将被建

议避免加重疼痛的活动，并保持正确的姿势。

预后，通过适当的治疗和生活方式的调整，患者的症状应该会

逐渐改善。然而，完全缓解症状可能需要几个星期到几个月的时间。