Record of Hospitalization

Name: Mr. H                                                              Sex: Male 

Age: 52                                                                       Profession: worker

Nationality: Saudi Arabia                                             Date of hospitalization: May 18, 2006 

Marital Status: Married 

Major complaints: Distending pains of the stomach duct for 23 years and the condition is getting worse since the recent two years.

Disease history: The patient suffered distending pains of the stomach duct for 23 years. There is relief after taking the western medicine. He did test in his local hospital and was diagnosed with stomach convulsion.

The stool is constipated and is as hard as a stone. Difficulty in bowel movement and 3-4 times a day. No tary stool.

In his country, the weather is hot and dry. He likes cold drinks. The patient had ulcerative colitis two years ago and was given operation for removing his intestinal segment partly. Since then the condition of abdominal distention and constipation became much more obviously. When the abdominal distention getting worse, there is painful sense radiates to his back waist as well. The condition could be under control by taking his western medicine.  

Individual History: Mr. H was born in Saudi Arabia and the living environment is hot and dry. He has an addiction of smoking and 20 cigarette each day. No addiction of drink alcohol. He once had a blood transfusion while having the operation two years ago. No allergy to any medicine or food.  

Physical examination: normal growth of his body and normal nutrition level. Clear mind and cooperative. No yellowish stain of his sclera. No enlargement of lymph nodes. No abnormality of his head and the five sense organs. Gray hair. Sanguine. Normal size of the pupillae and be sensitive to the reflection of light. No hyperaemia in the throat. No swelling of tonsil and thyroid gland. No varix. Thoracic cage is symmetrical and normal. Normal breath sound in the lungs. Heart rate is 70 times/ minute. No cacophony. The abdomen touches even and soft. There are pressing pains near to the left kidney. No rebound tenderness. Normal intestinal gurgling sound. Acanthi is in a normal formation. Knee jerk and tendon reflex are both OK.

Diagnosis: 

Chinese medicine: gastralgia (heat syndrome of the stomach and impairment of body fluids)

Western medicine: chronic atrophic gastritis  

May 19, 2006

Sleep well last night. The head of the left side pains. Distending pains of the stomach duct. Fullness and distention sense of the abdomen. Thready and rapid pulse. The tongue coating is thin and yellowish.   

May 20, 2006

Obvious abdominal distention. Good appetite. No any other discomfort.  

May 21, 2006

Abdominal distention is the same as before. The bowel movement was only once yesterday and the stool was constipated. Thready and rapid pulse. The tongue coating is thin and yellowish. Reddish tongue body. The treatment strategy will be regulating qi and relieving distension and fullness, nourishing yin and clearing heat.

rehmannia root  20g£¬ bupleurum root 5g£¬ toosendan fruit 10g£¬ adenophora root 12g, etc. 

May 22, 2006 

Today the patient had a CT test for head, and found no abnormality of the head. He was diagnosed with chronic atrophic gastritis checking by gastroscope.  

May 25, 2006

The patient said that there is obvious relief of stomach distending pains. Thready and rapid pulse. Thin and whitish tongue coating.  

May 29, 2006 

Abdominal distending pains and there are swollen pains around the bellybutton. Thready and rapid pulse. Thin and whitish tongue. The treatment strategy is nourishing yin and clearing heat.  

rehmannia root 20g£¬ white peony root 10g£¬ bupleurum root 6g£¬ magnolia root 7g£¬ etc 

June 2, 2006  

Very obvious relief of the stomach distending pains. String-like pulse. The tongue coating is thin and whitish.  

bupleurum root 10£¬ ovate atractylodes root 10£¬ white peony root 10g£¬ ophiopogon tuber12g, etc. 

June 5, 2006

Further relief of the stomach distending pains. Difficult in bowel movement. String-like pulse. Thin and whitish tongue coating.  

June 8, 2006

Great relief of the stomach pains. Normal food intake. Deep and fine pulse. The tongue coating is thin and whitish.

codonopsis root 15g£¬ bupleurum root 5g£¬ magnolia root 6g£¬ mulberry10, etc. 

June 11, 2006

No distending pains of the stomach duct. Obvious relief of the abdominal distention. Normal appetite. The patient left hospital in June 13, 2006.  

Doctor¡¯s advice for the patient:

1. Pay more attention to the daily diet

2. less smoking