Brief
Summary:
On Nov. 24, 2008, Silvia, from Kazakhstan, who has suffered from
hypothyroidism, fatigue and lack of strength for 5 years, was
hospitalized in our hospital. After 26 days TCM treatment here,
her condition became stable, and there were no obvious
discomforts. She was very satisfied with the result.
Record of Hospitalization
Name: Silvia Sex: Female
Age: 57 Profession: Psychological teacher
Birthplace: Kazakhstan Nationality:
Kazakhstan
Marital Status: Married Onset Season:
Light snow
Date of Admission: Nov. 24, 2008 Date of Record: Nov. 24,
2008
Complainer: The patient herself
First Medical Record
Date: Nov. 25, 2008 Time:
15: 00 p. m.
Silvia, a 57-year-old female, has suffered from fatigue and lack
of strength for 5 years. She was hospitalized in our hospital
for treatment at 15: 00 p. m. on Nov. 24, 2008.
Essentials for Diagnosis:
1.
The patient has suffered from fatigue and lack of strength for 5
years, accompanied by short breath, chest distress, insomnia,
dizziness, tinnitus, waist pains, aversion to cold and cold
limbs, much night urine, abdominal pains, abdominal distention,
cold pains and stiffness of the joints of the four limbs.
2.
The patient felt mouth dry and was fond of drinking. She also
had constipation. Her complexion was withered-yellow. Her tongue
coating was yellow. Her tongue was pale red with teeth marks on
the edges of the tongue. Her pulse was thready and weak.
3. T 36.5≧,
P 80 times/minute, R 20 times/minute, BP 120/80 mmHg.
4.
She grew normally with common nutrition. Her body was in a
positive posture and she was cooperative with clear mind.
Diagnostic Basis:
TCM: The patient has suffered from fatigue and lack of strength,
accompanied by short breath and chest distress. All the symptoms
were the manifestations of qi vacuity. It would result in poor
movement of the blood, and accordingly there were the symptoms
of insomnia, dizziness, tinnitus, etc. Qi and blood depletion
and vacuity would cause improper enrichment and supplement of
the bowels and viscera, so there were the symptoms of waist
pains, physical cold and cold limbs, much night urine, abdominal
pains, abdominal distention, cold pains and stiffness of the
joints of the four limbs. Because of the symptoms of excess in
extreme deficiency, the patient felt mouth dry and was fond of
drinking. She also had constipation. Her complexion was
withered-yellow. Her tongue coating was yellow. Her tongue was
pale red with teeth marks on the edges of the tongue. All the
symptoms are repletion manifestations of heat toxin brewing
internally.
Western Medicine: The patient has suffered from fatigue and lack
of strength, accompanied by short breath, chest distress,
insomnia, dizziness, tinnitus and waist pains. She was given the
examinations of T3, T4, and B ultrasound
which showed that she had hypothyroidism and chronic
pancreatitis.
Diagnostic Differentiation:
TCM:
1. The patient's vacuity taxation should be differentiated from
vacuity pattern. Vacuity taxation is mainly characterized by the
symptoms of insufficiency of essential qi when the chronic and
weak disease develops to serious stage. Moreover, all the bowels
and viscera will be affected. The course of the disease is
comparatively long and the attack of the disease is lingering.
However, vacuity pattern is generally characterized by the major
symptoms of the disease pattern.
2. Vacuity taxation should be differentiated from pulmonary
consumption which is due to the infection of germs of
tuberculosis and is a kind of infectious disease. The location
of the lesion lies in the lungs and yin vacuity is the mainly
pathological character of the disease. Pulmonary consumption is
mainly characterized by cough, coughing of blood, tidal fever
and night sweating in clinics. It is very different from vacuity
taxation.
Western Medicine: Chronic pancreatitis should be differentiated
from peptic ulcer. Chronic pancreatitis is mainly characterized
by repeated pains of the upper abdomen. The differentiation
between the two diseases depends on the disease period. Peptic
ulcer can be diagnosed by barium meal examination and
gastroscopy.
First Diagnosis:
TCM: 1. Vacuity taxation
2. Abdominal pains
Symptom identification: Vacuity of qi and blood, insufficiency
of kidney yang and heat toxin brewing.
Western Medicine: 1. Hypothyroidism
2. Chronic pancreatitis (30 years)
Plans for treatment strategy and nursing:
1. Routine
care of traditional Chinese internal medicine.
2. Diet
rich in protein and low in fat.
3. Grade
II care.
4. Herbal
tea (to boost qi, nourish the blood, clear heat and resolve
toxin): one dosage a day and drink twice.
Main herbs used in the herbal tea: baisheng (white ginseng),
gouqi (lycium berry), huangqi (astragalus
root), etc.
5. Acupuncture
and massage: once a day.
6. Have
more medical examinations if necessary.
Date: Nov. 25, 2008 Time:
9: 00 a. m
The patient has suffered from fatigue and lack of strength for 5
years, accompanied by short breath, chest distress, insomnia,
dizziness, tinnitus, waist pains, aversion to cold and cold
limbs, much night urine, abdominal pains, abdominal distention,
cold pains and stiffness of the joints of the four limbs. The
patient felt mouth dry and was fond of drinking. She also had
constipation. Her complexion was withered-yellow. Her tongue
coating was yellow. Her tongue was pale red with teeth marks on
the edges of the tongue. Her pulse was thready and weak.
TCM diagnosis: 1. Vacuity taxation
2. Abdominal pains
Symptom identification: Vacuity of qi and blood, insufficiency
of kidney yang and heat toxin brewing.
Western Medicine: 1. Hypothyroidism
2. Chronic pancreatitis (30 years)
TCM treatment strategy: Boost qi, nourish the blood, clear heat
and resolve toxin.
Prescription: Baisheng (white ginseng), gouqi (lycium berry),
huangqi (astragalus root), etc. 3
dosages in total.
Date: Nov. 26, 2008 Time:
9: 00 a. m.
There were
abdominal pains and abdominal distention. The patient could feel
obviously pressing pains of gastric cavity and the part below
the left ribs, but there were no enclosed masses and rebound
tenderness. Professor Zhang considered that it was due to
chronic gastritis and pancreatitis. The feedback of the
examinations was as follows: T3 showed 0.83
(comparatively low), and blood sedimentation was 25 mm/h
(comparatively quick). The other examinations including B
ultrasound, ECG, the function of the liver and kidneys, etc. all
were normal. Continue to take the former prescription.
Date: Nov. 27, 2008 Time:
9: 00 a. m.
The abdominal distention and the pains of the part below the
left ribs lessened, but she could feel the pains of gastric
cavity. The prescription was changed a little. 3 dosages in
total.
Date: Nov. 30, 2008 Time:
9: 00 a. m.
The pains of gastric cavity and the part below the left ribs had
obvious improvement. There were no pressing pains. Her abdominal
distention disappeared. Her spirit became better. But she felt
mouth dry and was fond of drinking. Her tongue coating was pale
yellow. The prescription was as follows: baishao (white
peony root), huangqi (astragalus root), sharen (amomum fruit)
and etc. 5 dosages in total.
Date: Dec. 4, 2008 Time:
9: 00 a. m.
The patient said her condition had further improvement. Continue
to take the former prescription. 4 dosages in total.
Date: Dec. 10, 2008 Time:
9: 00 a. m.
The pains of the upper abdomen and the part below the left ribs
as well as
abdominal distention completely disappeared. Her spirit was
good. Her diet, sleep, urine and bowel movement all were normal.
Continue to take the same prescription. 7 dosages in total.
Date: Dec. 16, 2008 Time:
9: 00 a. m.
The above symptoms were completely removed. Today the patient
complained about the joints pains of the four limbs. The others
were normal. She decided to leave the hospital on Dec. 19 with
taking 60 days herbal tea for further treatment. The
prescription was as follows: jianghuang (turmeric),
huangqi (astragalus root), duhuo (duhuo angelica root), etc. 2
dosages in total.
