Brief Summary:
On Sep. 13, 2010,
Mohammad, from The United Arab Emirates, who had suffered from
stomach pain and lumbar pain accompanied by belching of gas for
three year, was hospitalized in our hospital. He had achieved
significant improvement after 17 days TCM treatment here.
Record
of Hospitalization
Name:
Mahammad Sex:
Male
Age:
55 Marital Status: Married
Nationality:
The United Arab
Emirates Date
of Admission: Sep. 13, 2010
Complainer:
The patient himself
First Medical
Record
Date: Sep. 13,
2010 Time: 14: 00 p. m.
Mohammad,
a 55-year-old male, had suffered from
stomach pain and lumbar pain accompanied by
belching for three year.
He was hospitalized in our hospital for treatment at 14: 00 p.
m. on Sep. 13, 2010.
Essentials for Diagnosis:
1. The patient had
suffered from stomach pains accompanied with burning sense in
the stomach and belching for 3 years and lumbar pains for 2
years.
2. 3 years ago, the
patient began to feel stomach pains with burning sense in the
stomach. At that moment, he often belched. A year later, the
lumbar pains began, and it hurt when he pressed the waist.
Meanwhile, he also suffered from insomnia, astriction, hot sense
in the soles and palms in the night, loss of appetite, bitter
taste in the mouth and sometimes sweating at night. He often
feels tired and angry. He had the history of cardiovascular
expansion two years ago.
3. T 36.3≧,
R 20 times/minute, P 70 times/minute, BP 120/80mmHg.
4. He grew normally
with common nutrition and had natural expression. His mind was
clear. His body was in a positive posture and he was cooperative
with clear mind.
5.
No thoracic deformity. Eyes'
action was flexible. Thyroid was normal. Sound of breath was
bilaterally normal on auscultation. No sound of pleural
friction. Cardiac rhythm was regular. Heart border was a little
irregular. Sound of blood vessel is normal. Heart beat was 70
times/minute.
6. The abdomen was soft. There wasn't sound of pathological
gastric motility. No enlargement of liver and spleen. Gall
bladder was no swelling. No Mcburney's point tenderness. Tongue
was red with thin greasy tongue coating. The pulse was a little
floating.
7. The patient had no food allergy or drug allergy.
8. Report of electrocardiogram: sinus rhythm, and the myocardial
infarction was not ruled out. No accessory examination.
Diagnostic Basis:
TCM: The patient had suffered from stomach tenderness
accompanied with burning sense in the stomach and belching.
There were pains on the waist with the feeling of pulling down.
The main symptoms
leaded to the diagnosis of stomach pain and lumbar pain,
Western Medicine: The patient had suffered from stomach
tenderness accompanied with burning sense and belching. There
were pains on the waist, too.
Diagnostic
Differentiation:
TCM (Traditional
Chinese Medicine): The patient's stomach pain should be
differentiated from cardialgia. To the cardialgia, painful part
is the middle and the lower part of the chest. However, stomach
pain happens at the abdomen accompanying with belching. So they
are not difficult to be distinguished.
Western Medicine:
The disease could be tested by B ultrasound examination and
Cholecystitis phase.
First Diagnosis:
TCM (Traditional
Chinese Medicine): stomach pain and lumbar pain
Symptom
identification: liver qi invading the stomach, obstruction of
vessel and network by dampness-cold.
Western Medicine
diagnosis: gastritis and lumbar pain
Treatment strategy
and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade II care.
3. Common diet.
4. TCM strategy:
Course the liver and resolve depression, and tonify spleen and
clear the fire, and free the network vessels.
5. Herbal tea: one dosage a day and drink twice.
6. Acupuncture and massage: once a day.
7. Have more medical examination if necessary.
Date: Sep. 14, 2010 Time:
10: 00 a. m.
The patient had suffered from stomach pain and lumbar pains
accompanied by burning sense in the stomach and sometimes
belching and lumbar tenderness for 3 years. Meanwhile, he had
the symptoms of insomnia, loss of appetite, frequent feeling of
tiredness and upset, bitter taste in the mouth, hot sense in the
soles and palms, sweating and frequent urination at night,
floating pulse, and red tongue with greasy coating. Professor
Zhang believed that he had suffered from stomach pains and
lumbar pain due to liver qi invading the stomach, obstruction of
vessel and network by dampness-cold. The belching was caused by
ascending counter-flow of stomach qi. Obstructed cold-dampness
inflew network vessels, which was the reason of lumbar pains. So
the treatment strategy was to course the liver and resolve
depression, tonify spleen and clear the fire, and free the
network vessels. The prescription was as follows: zhuru (bamboo
shavings),
chaihu (bupleurum
root),
baizhu (ovate
atractylodes root ),
etc. 3 dosages in total.
Date: Sep. 16, 2010 Time:
9: 00 a. m.
According to the feedback, there was much improvement as to the
stomach pains, belching and burning sense in the stomach. But
there were no changes to lumbar pains. The tongue coating was
getting light, and the mouth was not so bitter.
Date: Sep. 22, 2010 Time:
9: 00 a. m.
The patient complained sharp pains on the twist with tenderness.
It's hard to him to turn over. The tongue was red, but its
coating was white and slippery. The pulse was floating.
Date: Sep. 24, 2010 Time:
9: 00 a. m.
The symptom of
lumbar pains was reduced. But the patient was vexed and
suffering from insomnia.
Date: Sep. 29, 2010 Time:
9: 00 a. m.
His spirit was good. The symptoms of lumbar pain and stomach
pain disappeared, so did belching. The patient can move the body
normally. To consolidate the improvement, the patient decided to
take 60-day dosages with him when leaving.