Brief Summary: On May 9, 2010, Inna from Kazakhstan, who has suffered from continuous pains in the upper abdomen, was hospitalized in our hospital. She has achieved obvious improvement after 21 days TCM treatment here.

 

Record of Hospitalization

Name: Inna                                                                                                          Birthplace: Kazakhstan

Sex: Female                                                                                                         Profession: Engineer

Age: 60                                                                                                               Date of Admission: May 9, 2010

Nationality: Kazakhstan                                                                                     Date of Discharge: May 30, 2010

Marital Status: Married                                                                                     Children-bearing: one boy and one girl

Character: Irritability                                                                                           Living Environment: humid

Food: light food, no drinking, smoking

Complainer: The patient herself

Major complaint: Continuous pains in the upper abdomen for 10 years.

Disease history: Have history of hepatitis, trigeminal neuritis. No tuberculosis, schistosomiasis and other infectious diseases. No history of traumatic injury and surgery. No allergic history of food or medicine. No history of blood transfusion. The history of preventive vaccination was unknown.

Personal history: She was born in Kazakhstan. No addiction of wine drinking. She smokes. She likes light food and her living environment is humid. She is irritability.

Family history: Her parents are both healthy.

 

                                                                                       First Medical Record

Date: May 9, 2010                                             Time: 20: 30 p. m.

Inna, a 60-year-old female, has suffered from continuous pains in the upper abdomen for 10 years. She was hospitalized in our hospital for treatment at 20: 30 p. m. on May 9, 2010.

 

Essentials for Diagnosis:

1. The patient has suffered from continuous pains in the upper abdomen for 10 years.

2. 10 years ago, because of keeping in bad mood, the patient suffered from pains in the upper abdomen. She started to get treatment at a local hospital for reducing inflammation and relieving stomachache, but she didn't note any improvement. About 1 year ago, the pains in the upper abdomen became worse and she was diagnosed with erosive gastritis and chronic pancreatitis. With the treatment for stopping pains and reducing inflammation, but the effects were not so good.

Her present symptoms were as follow:

There were continuous pains in the upper abdomen which was worse after meal. The epigastric part has burning sensation. The pains were worse after having the meals. She also suffered from abdominal distension, pains in the ribs, headache, upset, dry mouth, constipation, yellowish tongue with crack and thread like pulse.

3. T 36.2≧, R 20 times/minute, P 82 times/minute, BP 140/80mmHg.

4. She grew normally with common nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. Her body was in a positive posture and she was cooperative with clear mind.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sounds of pleural friction rub. Heart border was normal. No pathological murmurs on auscultation. The stomach cavity and the left ribs were significant painful. No rebound tenderness.

6. Accessory examination: In April 2009, at a local hospital, the patient had gastrocopy and type-B ultrasonic test. She was diagnosed with erosive gastritis and chronic pancreatitis.

 

Diagnostic Basis:

TCM: The patient's agitation caused by binding depression of the liver qi and obstruction of epigastric qi. The continuous pains in the upper abdomen of ten years caused by the transverse dysfunction and invasion of the stomach. Therefore, the gastric cavity was burning. The depression of the liver and qi led to flanc pains, headache and insomnia. Meanwhile, qi stagnation and the obstruction of viscera and qi caused constipation. According to the symptoms of the tongue and pulse, she was diagnosed with gastralgia and flank pains.

Western Medicine: The patient has suffered from continuous pains in the upper abdomen for 10 years. The condition got worse 1 year later. And she felt obvious pains when the left rib and the gastric cavity were pressed on. Then, the patient was diagnosed with erosive nephritis and chronic pancreatitis by gastroscopy.

 

Diagnostic Differentiation:

TCM: The patient's gastralgia should be differentiated from abdominal pains. The gastralgia usually occurs close to the heart. However, abdominal pains usually occur under epigastric part. So they are not difficult to be distinguished.

Western Medicine: The patient's erosion nephritis should be differentiated from angina pectoris which usually occurs in the upper epigastric part or the heart. The location, property and degree of the pains are all different from angina pectoris. So they are not difficult to be distinguished.

 

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: 1. gastralgia 2. pains in the flank part

Symptom identification: qi stagnation and depression of heat.

Western Medicine diagnosis: 1.erosive nephritis 2. chronic pancreatitis

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Under the care of a companion.

4. Common diet.

5. Herbal tea: transforming the liver, rectifying qi, clearing heat and enriching yin.

The main herbs as follows: bupleurum, bitter orange, etc.

Using the water to decoct it, four dosages in total, one dosage a day and drinking twice.

6. Acupuncture and massage once each day.

7. Perfect all the examinations.

 

Date: May 11, 2010                                   Time: 10: 00 a. m.

The patient did not complain any special discomfort. So the treating strategy was the same as before.

　

Date: May 12, 2010                                   Time: 10: 00 a. m.

The patient said that her head, the upper abdomen and the right ankle were painful. The examination for urine, the liver and etc, showed all normal. So the acupuncture treatment was a little changed. 

　

Date: May 13, 2010                                   Time: 10: 00 a. m.

The patient said that the pains of the upper abdomen were reduced a little but the burning sensation; abdominal distension and headache still existed. So the head treatment was added in the acupuncture to free network vessels.

　

Date: May 20, 2010                                   Time: 10: 00 a. m.

The patient said that the pains of the upper abdomen were improved obviously. Meanwhile, abdominal distension and headache disappeared. Good sleep at night. So the acupuncture and massage were the same as before.

　

Date: May 30, 2010                                    Time: 10: 00 a. m.

The patient said that the pains of the upper abdomen and burning sensation disappeared without abdominal distension and headache. Good sleep at night. Today, the patient felt her health was alright and would leave the hospital. The doctor advised her to take the herbs home to continue the treatment, take care of the diet and avoid wind-cold or catching a cold.