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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