Record of Hospitalization

Name: Pan Fengxiang                                                                                             Sex: Female

Age: 50                                                                                                                 Marital Status: Married

Nationality: China                                                                                                 Date of Admission: Jan. 31, 2013

Companion: Alone

First Medical Record

Date: Jan. 31, 2013                               Time: 9:45 a.m.

This 50-year-old lady had been suffering distending pains over her gastric cavity, accompanied by vomiting, nause, bitterness and dryness in her mouth for more than two years. The patient was hospitalized in our hospital for TCM treatment at 9:45 a.m. on January 31, 2013.

Essential for Diagnosis:

1. The patient had been suffering distension pains over her gastric cavity, accompanied by vomiting, nausea, bitterness and dryness in her mouth for more than two years. Her condition became more severe nearly one month. She often suffers bitterness and dryness in her mouth. She felt vague discomfort over her right rib part. She did a subtotal hysterectomy in the year of 2001. She has no history of allergy of any food and medicine.

2. When Mrs. Pan came to our hospital, she suffered from distension pains over her gastric cavity. She felt vague discomfort over her right rib part. There was heat over her hands, feet and heart. She felt vexed. She also felt nausea and vomiting. She felt relaxed after sighed. There were pains over her neck and shoulders. Her lumbar and limbs were painful also. She had much leucorrhea, which was yellowish and with odors. Her stool was loose. Urination was normal.

4. T: 37°C   R: 22 times/minute    P: 76times/minute   BP: 120/72mmHg

5. The patient grew normally with a little fatty body shape. Her spirit activity was not good. Skin over her whole body and sclera did not show any yellowish symptoms. There was a bean-sized lymph node near her left neck closing to the deep point of her collarbone. It did not show any pressing pains. There were pressing pains on the middle part of her left sternocleidomastoid. Pressing pains also showed over her cervical vertebra and shoulders. The size and formation of his thorax were normal. No enlargement with her heart. Rhythm of his heart was 76 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. Her tongue coatings were yellowish, thick and dry. Her pulse was wiry and rapid.

Diagnostic Differentiation:

TCM:

The patient suffered distending pains over her gastric cavity, accompanied by nausea, dry vomiting, bitterness and dryness in her mouth and vexation. She was easy to get angry with her family members, and after that her conditions became more severe. This was due to the stagnation of liver qi, and then that stagnation led to internal heat. The heat intruded the stomach, leading to disharmony of the liver qi. Therefore, distension symptom showed out. Bitterness and dryness in her mouth, thick and yellowish tongue coating, red tongue, wiry and rapid pulse were caused by dampness and heat in the liver and gallbladder. Much yellowish leucorrhea with odors was caused by dampness and heat in the liver channels. According to the theory of TCM, his symptom was due to dampness and heat in the liver channels invading the stomach. Treatment strategy should be soothing the liver and relieving depression as well as removing the dampness and heat in the liver channels and harmonizing the stomach.

Western Medicine diagnosis:

1. Distension pains over her right upper quadrant, accompanied by nausea, dry vomit, bitterness and dryness in her mouth

2. Pressing pains over her right upper quadrant

3. Sore and swelling pains over her lumbosacral region. Much yellowish leucorrhea with odors.

First Diagnosis:

TCM: Gastralgia.

Symptom identification: dampness and heat in liver channel, and liver depression invading the stomach.

Western medicine diagnosis:  1. Chronic superficial gastritis

                         2. Chronic cholecystitis

                         3. Chronic pelvic inflammatory disease

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ care.

3. Soft food with lower salt and fat.

4. Pathogenesis: dampness and heat in the liver channels invading the stomach.

5. TCM strategy: soothing the liver and relieving depression as well as removing the dampness and heat in the liver channels and harmonizing the stomach.

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

7. Acupuncture and massage: once a day

8. Have more medical examination if necessary.

Date: Feb. 1, 2013                                             Time: 9:00 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient this morning. The patient complained that she had been suffering from distending pains over her gastric cavity, accompanied by vomiting, nausea, bitterness and dryness in her mouth for more than two years. Her condition became more severe nearly one month. She often suffers bitterness and dryness in her mouth. She felt vague discomfort over her right rib part. She did an operation of subtotal hysterectomy in the year of 2001. She was very easy to get angry with her family. The patient grew normally with a little fatty body shape. Her spirit activity was not good. Skin over her whole body and sclera did not show any yellowish symptoms. There was a bean-sized lymph node near her left neck closing to the deep point of her collarbone. It did not show any pressing pains. There were pressing pains on the middle part of her left sternocleidomastoid. Pressing pains also showed over her cervical vertebra and shoulders. Her tongue coatings were thick and yellowish. Her pulse was wiry and rapid. According to the above symptoms of the patient, after operation of subtotal hysterectomy, she got irritable mood, and for a long time, the stagnation of qi infected her liver, and then the stagnation of liver qi became internal heat intruding the stomach. Therefore, that led to swelling pains over her gastric cavity. She often felt bitterness and dryness in her mouth, and this course of ill has been more than two years, leading to dampness and heat obstructing the liver channels. Much yellowish leucorrhea with odors, thick and yellowish tongue coatings, wiry and rapid pulse were due to hypertension of irascibility or liver heat. Therefore, treatment for the patient should be soothing the liver and relieving depression as well as removing the dampness and heat in the liver channels and harmonizing the stomach.

Date: Feb. 2, 2013                                             Time: 9:00 a.m.

The patient said bitterness and dryness in her mouth were turning better. Pains over her nasion were reduced. Swelling feeling of her stomach was reduced a little bit. Her tongue coating changed from thickness to thinness, but still dry. Her pulse was wiry and rapid.

Date: Feb. 3, 2013                                             Time: 9:00 a.m.

The patient said bitterness and dryness improved obviously. Gastric distension was reduced a lot. Leucorrhea was less. Her tongue coating was yellowish and thin. Her pulse was wiry and rapid, but softer than before.

Date: Feb. 6, 2013                                             Time: 9:00 a.m.

The patient complained that she still felt slightly dryness and bitterness in her mouth. She felt discomfort in her throat. Swelling feeling in her stomach was reduced. Leucorrhea was reduced obviously. Pressing pains over her right upper quadrant were reduced a lot. Her tongue coatings were yellowish and thin. Her pulse was thready, wiry and slightly rapid.

Date: Feb. 8, 2013                                             Time: 9:00 a.m.

The patient said that after treatment in our hospital with the comprehensive treatment of herbal tea, acupuncture, massage, TCM plaster and infrared treatment machine, her conditions were turning better a lot. Gastric distension was reduced obviously. Bitterness and dryness were better. Her spirit was also much better than before. Pains over her neck and shoulders almost disappeared. Pains over her lumbosacral portion were reduced. Leucorrhea was reduced obviously with no more odors. Urine and stool were normal. Pressing pain points over her left sternocleidomastoid and both shoulders disappeared. There were no more obvious pressing pains over her right upper quadrant. The size and formation of his thorax were normal. No enlargement with her heart. Rhythm of his heart was 72 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. The patient asked to discharge from our hospital today.

Doctor’s advice after leaving hospital:

1. Avoid wind-cold, maintain good moods, and take care of the diet.