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Record of Hospitalization
Name: Warda
Gender: female
Age:
4 Nationality:
Pakistan
Height: 70
centimeters Weight: 15 Kilos
Time of Hospitalization: July 23,
2005, 11:00 am
Major complaint: Beta-thalassemia
found when she was born. After she was born for four months, she has to get
blood transfusion monthly. About 350 milliliters of blood
transfusion each time.
Last
evening, accompanied by her grandmother, parents and 8 years old sister, she
arrived at our hospital after the long journey from Pakistan.
The father introduced that during
recent three and half years, every month the patient accepts blood transfusion
of 350 milliliters. Before the blood transfusion, the hemoglobin is 8.1 to 8.15.
After the blood transfusion, the hemoglobin raises to 14.00. Half month after
the blood transfusion, the hgb drops to ten or eleven. 20 days later, it drops
to nine.
Before the blood transfusion, when
the hgb is low the patient feels very fatigue.
No loss of hair, no tinnitus, no
dry eyes, no nasal blockade and discharge. Drinking much water daily, prefer
cold water. Dislike bitter foods and spicy foods. Appetite is normal, but when
the hemoglobin drops to the lowest level, the food intake is reduced fifty
percent. The favorite foods are mango juice, noodles, rice, and chicken.
She does not catch common cold
often, about once a year, also very slight. Rare coughing. No phlegm.
She is quite active during 15 days
after transfusion. The following 15 days, she is inactive.
No shortness of breath, no
palpitations. She never complains abdominal pains.
The stool is normal, once a day,
good shape. The urine is sometimes darkish, and sometimes yellowish.
No back pains. No aversion to
coldness.
Sometimes, the father felt her
hands little lit hot.
Much night sweat on the head,
almost everyday and every season, especially in winter.
Never found edema over the body.
The family has the same case such
as the brother of her father. The case history is 7 years. Every month also has
to take blood transfusion.
When touch the body, three is no
pain anywhere. The abdomen is soft but enlarged.
The tongue tip is reddish, the
tongue coating is yellowish and greasy. The pulse is thready and weak.
The last blood transfusion is on
July 18, 2005.
Diagnosis: Beta-thalassemia
(western medicine)
Blood deficiency and deficient fire (Chinese medicine)
Treatment strategy: Enrich qi and
blood, tonify spleen and liver, clear deficient fire.
Formula:
Chinese yam
4g poria 4 g, cooked rehmannia root 4g, etc.
Two dosages
are prescribed. One dosage a day, twice a day. 40 milliliters each time.
Considering the too young baby may dislike drinking the herbal tea, putting some
sugar into the tea.
Daily TCM
baby massage is prescribed, one hour each day.
Dr. Ming
July 24, 2005. The appetite for
last dinner is good. The sleep last night is OK. Drinking much water yesterday.
The tip of tongue is reddish. The tongue coating is slightly less yellowish and
thick.
The
girl accepts the tea well.
tangkuei root 4 g,
moutan bark 4g, poria 4 g, etc.
Two dosages are
offered.
Dr. Ming
July 25, 2005. The father said that
the patient accepts tea well. Drink 60 ml tea fully each time. The urine is less
yellowish. The bowl movement is normal, once a day.
Night sweat is on the head only.
The other part of the body has no sweat. The tongue tip is still red. The
coating is yellowish and greasy. B-ultrasonic shows no abnormality.
Dr. Ming
July 26, 2005. The patient¨s
parents said that Warda feels well, the appetite and sleep are normal. No night
sweating on the head, this is a good change. The patient is spirited and more
active.
The hemoglobin checked yesterday is
13.20 as below. This is the result after three days treatment.
The
last blood transfusion is on July 18. So this is also the eighth day after the
latest blood transfusion. In the past, according to the routine, the hemoglobin
should drop to 12.5 or so.
The
same formula 2 dosages.
Dr. Ming
July
27, 2005. The patient¨s parents said that Warda has good appetite and sleep. She
is very active yesterday.
Drinking more water. The urine is whitish. The bowl movement is normal, once a
day.
The
tongue tip is less reddish. The pulse is little bit stronger. This morning the
sweating on head is reduced 80%.
Dr. Ming
July
28, 2005. The patient¨s father said Warda was active yesterday. The appetite is
normal and a little bit more food-intake than at home. The urine is whitish.
Drinking much water yesterday. The bowl movement is normal. The night sweating
on the head was very slight last evening after going to bed, approximately 15%
or so.
She
is so cooperative to drink the tea even without sugar inside the tea.
The
pulse is little bit stronger and the tongue tip is less reddish. The tongue
coating is still slight yellowish and greasy.
codonopsis root 4
g, Chinese yam 4 g, poria 4 g, etc.
Two dosages are advised. Daily
massage is continuing.
Dr. Ming
July 29, 2005. The appetite and
sleep are normal. Very active. No night sweat over the body and on the head.
The urine is white. The bowl
movement is normal, once a day.
She likes the herbal tea and
massage. The tongue tip is less reddish.
Check the blood again tomorrow
morning.
Dr. Ming
July 30, 2005. The appetite and
sleep are normal. The food intake increasing about 20% compared to the state in
Pakistan. She is more active to play with her parents and sister who is eight
years old.
There is no sweating on the body
and the head.
Today, make the blood test. The
result is very good as below.
So
the hemoglobin remains the same level as one week ago when she was starting our
TCM treatment. According to the routine her hemoglobin should drop to 115g/L or
so. This is the twelfth day after the last blood transfusion. The doctors in our
hospital and the parents and the grandmother of the patient feel very happy with
this result. Thanks for the good cooperation of the 4 years old baby to drink
the herbal tea in such a cooperative way.
Two
days later, the patient and her family will have to leave our hospital. The
patient¨s father said maybe the brother of her mother will come from Pakistan to
Huaihua to take care of the patient and her mother for another month to
consolidate the good treatment result.
Anyway, the father of the patient asks for one month herbal tea supply from us
so that the treatment will not be paused.
Dr. Ming
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The results of the laboratory check in our hospital are scanned as below to show
the improvement.
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