Brief Summary:
On
March 23, 2016, Ms. Pan Chunmin, from Zhongfang County, who had
been suffering from stuffy pain and flatulence over her
epigastrium for 20 years, accompanied with vomiting and
hiccough, being severe for half a month. She was hospitalized in
our hospital. Her condition got great improvement after 16 days
TCM treatment with the help of Acupuncture, Herbal tea and Tuina
in our hospital.
Record of Hospitalization
Name: Ms.
Pan Chunmei Sex: Female
Age: 45
Marital Status: Married
Nationality: China
Date of Admission: March
23, 2016
Companion: Alone
First Medical Record
Date: March
23, 2016 Time: 12:00
a.m.
This
45-year-old woman had been suffering from abdominal distension
and pain, accompanied with vomitting and hiccough, being severe
for half a month. The patient was hospitalized in our hospital
as a patient with chronic superficial gastritis for TCM
treatment at 12:00 a.m. on March 23, 2016.
Essential for Diagnosis:
1. The
patient said 20 years ago she had abdominal distension and pain,
accompanied with vomitting and hiccough. Her bowel movement was
abnormal. The function of digestion was not bood, it could not
digest the food. She felt stomach distending, even she ate less.
Sometimes she had bitter mouth, constipation and flatus. She
took the treatment for many years, there was no improvement. On
March 8th, 2016 the patient went to take a stomachoscopy, the
result reported that the patient sufferred with chronic
superficial gastritis. In order to relife the pain, the patient
came to our hospital for TCM treatment. The patient have the
following medical history, cervical spondylosis, frozen shoulder
and gonitis. She always had joint pain and it is difficult to
move. The activity was limited.
2. When
the patient came to our hospital, her spirit status was not
good. She had distending pains over her epigastrium. She felt
bitter in her mouth, stuffy pain and distending over her
abdomen, accompanied with vomitting and hiccough. To defecate
four times a day, the food was not digested. Her urination was
normal. There was obvious pain over her shoulder joints, lower
back and knee-joints. And she had headache as well. She was
afraid of cold, yet sweating over her soles and palms. It was
difficult to move, her sleeping was not good.
3. T:
36.5＜C R: 20 times/minute P: 80 times/minute BP:
130/90mmHg
4. The
patient grew normally. She was alert and cooperative. She had
chronic sick facial complexion. She moved slowly. There was no
sign of yellow sclera or yellowish skin and also no enlargement
on the superficial lymph node of her whole body.
Facial features were normal without masses and
pressing pains.
The pupils were round and approximately equal in size. The
pupillary reaction to light was sensitive. Her ears were normal
without secreta and pressing pain. Her hearing was normal.
Her neck was soft without resistance. While she
was hard to turn her neck, when she turn her neck, it made the
pain over her right shoulder. There was no enlargement over her
thyroid.The jugular vein was of no engorgement. Her windpipe
appearance was good and in the center. Her chest was
symmetrical. Sound of breathing in the lungs was clear, without
any rhonchi. Rhythm of her heart was 80 times per minute. Heart
rate was regular with no murmurs. Her abdomen was soft with no
pressing pains and rebound tenderness. There was no sign of
deformity over her spine. There was obvious pressing pains close
to her third or fouth lumbar vertebra. And there was obvious
pain over her knee-joints. The meningeal irritation sign was
negative. There were no pathological reflections, but the
physiological reflections existed. The tongue body was light red
with white and thin coating. The pulse was deep and string.
Diagnostic Differentiation:
TCM:
Impediment and stomachache.
Western Medicine diagnosis:
1.
rheumatoid arthritis
2.
chronic superficial gastritis
Treatment strategy and nursing:
1.
Routine care of traditional Chinese internal medicine.
2.
Grade Å care,
slight diet, avoid spicy food.
3.
Completed the related examination,
three routine inspection, the function of the kidneys and the
liver, HB 5 test, blood fat, blood sugar, anti-O, RF and IMX.
4.
Herbal tea: one dosage a day and drink twice
5.
Acupuncture and massage: once a day.
6.
Avoid wind-cold, regular daily life, have a good mood and take
care of diet.
Date:
March 23, 2016 Time:
12:00 a.m.
Dr. Luo,
doctor-in-charge, paid a visit to the patient. The patient
complained that 20 years ago she had abdominal distension and
pain, accompanied with vomitting and hiccough. Her bowel
movement was abnormal. The function of digestion was not bood,
it could not digest the food. She felt stomach distending, even
she ate less. Sometimes she had bitter mouth, constipation and
flatus. She took the treatment for many years, there was no
improvement. On March 8th, 2016 the patient went to take a
stomachoscopy, the result reported that the patient sufferred
with chronic superficial gastritis. In order to relife the pain,
the patient came to our hospital for TCM treatment. The patient
have the following medical history, cervical spondylosis, frozen
shoulder and gonitis. She always had joint pain and it is
difficult to move. The activity was limited. To defecate four
times a day, the food was not digested. Her urination was
normal. There was obvious pain over her shoulder joints, lower
back and knee-joints. And she had headache as well. She was
afraid of cold, yet sweating over her soles and palms. Her
sleeping was not good.
The tongue body was light red with white and thin coating. The
pulse was deep and string.
Date:
March 24, 2016 Time:
10:00 a.m.
The
patient said there was no obvious improvement. Taking the herbal
tea to observe the effect.
Date:
March 25, 2016 Time:
9:00 a.m.
The
patient said the discomfort, bitter mouth and distending pain
improved. And the flatulence in the lower abdomen also relieved.
Date:
March 26, 2016 Time:
9:00 a.m.
The
patient was in a good spirit status. She said the flatulence in
her abdomen obviously relieved. And the vomitting and hiccough
both improved.
Date:
March 30, 2016 Time:
9:00 a.m.
The
patient said the vomitting and hiccough disappeared, and the
food could be digested completely. Her bowel movement was
better.
Date:
April 03, 2016 Time:
9:00 a.m.
The
patient said the distending pain and flatulence in her abdomen
almost disappeared. The vomitting and hiccough disappeared
completely. The pain over her shoulder joints, her lower back
and knee-joints reduced obviously, the same as her headache. And
the activity improved.
Date:
April 05, 2016 Time:
9:00 a.m.
The
patient said the condition was stable. The symptoms almost
disappeared and her condition was better day by day. The pain
over her shoulder joints, her lower back and knee-joints also
disappeared. Her sleeping was normal.
Date: April 08,
2016 Time: 9:00 a.m.
The patient decided to leave the hospital today.
She had recovered.
