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Brief Summary: On Mar. 18, 2009, Natalia from Russia, who has suffered from stomach pains, was hospitalized in our hospital. She has achieved obvious improvement after 14 days TCM treatment here.

 

Record of Hospitalization

Name: Natalia                                                                                                      Birthplace: Russia

Sex: Female                                                                                                          Profession: Doctor

Age: 42                                                                                                                 Date of Admission: Mar. 18, 2009

Nationality: Russia                                                                                               Date of Record: Mar. 18, 2009

Marital Status: Married                                                                                       Onset Season: Vernal equinox

Complainer: The patient herself

 

First Medical Record

Date: Mar. 18, 2009                                      Time: 24: 00 p. m.

Natalia, a 42-year-old female, has suffered from recurrent attacks of abdominal distention for 6 years. She was hospitalized in our hospital for treatment at 24: 00 p. m. on Mar. 18, 2009.

Essentials for Diagnosis:

1. The patient has suffered from recurrent attacks of abdominal distention for 6 years.

2. In 2003, the patient began to feel abdominal distention without obvious reasons. At that moment, she didn¡¯t pay much attention to it and hadn¡¯t taken any examination and treatment. Later her condition gradually became worse. Then she went to a local hospital for treatment. Her condition was slightly improved after the treatment. In order to search for further treatment, she came to our hospital at 24: 00 p. m. on Mar. 18, 2009. She had pale red tongue, thin yellow tongue coating, deep and thready pulse.

3. T 36.1¡æ, R 20 times/minute, P 80 times/minute, BP 120/80mmHg.

4. She grew normally with common nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. Her body was in a positive posture and she was cooperative with clear mind.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The patient had the symptoms of abdominal distention, belching and rumbling intestines.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient has suffered from recurrent attacks of abdominal distention for 6 years. The stomach is the bowel of grain and water, and it is normal when there is free downbearing. The damage due to diet or evil qi invading the stomach will result in impaired harmonious downbearing of the stomach and splenic transformation failure. These conditions eventually cause the problem of the stomach pains.

Western Medicine: The patient has suffered from recurrent attacks of abdominal distention for 6 years, accompanied with the symptoms of belching, rumbling intestines and waist pains.

Diagnostic Differentiation:

TCM: The patient¡¯s stomach pains should be differentiated from glomus and fullness. The onset part of the diseases lies in the stomach duct. Stomach pains are characterized by the symptoms of distention, pains and pressing pains. However, glomus and fullness is mainly characterized by dull pains, glomus blockage, fullness and oppression. But there are no pressing pains. So they are not difficult to be distinguished.

Western Medicine: The patient¡¯s stomach pains should be differentiated from true heart pain (angina pectoris). Stomach pains usually occur in young adults. The part suffering from the pains is located in the stomach duct of the upper abdomen. The location is comparatively low. The pains are characterized by distending pains and dull pains, without sharp pains. The disease is closely connected with the diet, and usually there are the symptoms of acid swallowing, belching, nausea, vomiting, etc. On the contrary, angina pectoris mostly occurs in old age. The part suffering from the pains is located in the right front part of the chest and left prothorax. The location is comparatively high. The pains are characterized by stabbing pains, gripping pains, sometimes with sharp pains. Usually there are the symptoms of palpitation, shortness of breath, sweating, etc. So they are not difficult to be distinguished.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Stomach pains

Symptom identification: insufficiency of spleen qi, qi stagnation middle burner.

Western Medicine diagnosis: Chronic gastritis

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Common diet.

4. TCM treatment strategy: fortify the spleen, boost qi, move qi and disperse distention.

5. Herbal tea: one dosage a day and drink twice.

6. Acupuncture and massage: once a day.

7. Have more medical examination if necessary.

 

Date: Mar. 18, 2009                                      Time: 11: 00 a. m.

The patient has suffered from recurrent attacks of abdominal distention for 6 years. Six years ago, she felt abdominal distention without obvious reasons. Later her condition gradually became serious. She felt better after the treatment. At present, she had the symptoms of abdominal distention, belching, rumbling intestines and waist pains. She felt mouth dry and was fond of drinking. There were no symptoms of headache and dizziness. She had frequent urination. Her bowel movement was normal. She had deep and thready pulse, pale tongue, thin and yellow tongue coating. Professor Yang believed that she had suffered from stomach pains due to insufficiency of spleen qi, qi stagnation middle burner. So the treatment strategy was to fortify the spleen, boost qi, move qi and disperse distention. The prescription was as follows: baizhu (ovate atractylodes root), chuanxiong (ligusticum root), chenpi (tangerine peel), etc. 4 dosages in total.

 

Date: Mar. 19, 2009                                       Time: 9: 00 a. m.

According to the feedback, the routine examinations of the blood, urine, bowel movement were normal.

 

Date: Mar. 21, 2009                                       Time: 9: 00 a. m.

The patient said her abdominal distention was obviously improved, but she still had belching. The symptom of her rumbling intestines lessened and that of dry mouth was better than before. The former prescription was changed a little. 5 dosages in total.

 

Date: Mar. 26, 2009                                       Time: 9: 00 a. m.

Her spirit was good. The symptoms of abdominal distention and belching disappeared. She didn¡¯t feel mouth dry. But there were slight waist pains. The former prescription was changed a little. 5 dosages in total.

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