Brief Summary:
On Nov. 24, 2008, Diana, from Kazakhstan, who has suffered from
annexitis and intermittent pains of the lower abdomen for one
year, was hospitalized in our hospital. She has achieved
significant improvement after about 26 days TCM treatment here.
¡¡
Record of Hospitalization
Name:
Diana Birthplace: Kazakhstan
Sex:
Female Profession: Market regulation
Age:
32 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 Report
Date: Nov. 25, 2008 Time:
9: 00 a. m.
Diana, a 32-year-old female, has suffered from bilateral pains
of the lower abdomen for one year. It became more serious for
one month. She was hospitalized in our hospital for treatment at
15: 00 p.m. on Nov. 24, 2008.
Essentials for Diagnosis:
1. The
patient felt abdominal pains, especially bilateral pains of the
lower abdomen.
2. During
2007, the patient felt abdominal pains without obvious reasons,
especially bilateral pains of the lower abdomen. She was given B
ultrasound examination and laparoscopy in the local hospital as
well as in Beijing, but the findings were different. She was
also given celoscope operation, but it was not successful.
Moreover, she hadn¡¯t taken proper treatment after operation.
During 2008, she was hospitalized in the hospital for two times
and had been given antibiotics for treatment.
3. T
36.2¡æ,
P 80 times/minute, R 20 times/minute, BP 100/70 mmHg.
4. She
grew normally with common nutrition. Her body was in a positive
posture and she was cooperative with clear mind.
5. There
were obviously pressing pains on her abdomen, but no rebound
tenderness. Her vaginal discharge was yellow. She had scant
menstrual flow and the period lasted about 2-3 days. During the
period, she felt the pains of the waist and abdomen. She had the
symptoms of distending pains of the breasts and dry mouth during
and after the period. Her diet, urine and bowel movement all
were normal. Her sleep was good. Her tongue coating was yellow
and slightly slimy. Her tongue was red-purple. Her pulse was
thready and weak.
Diagnostic Basis:
TCM: The patient has suffered from abdominal pains for one year.
It became serious for one month. The symptoms such as yellow
vaginal discharge, yellow and slightly slimy tongue coating, and
dry mouth were the manifestations of damp-heat brewing. And
damp-heat brewing would result in obstruction of the movement of
qi and the blood, so the patient felt abdominal pains and
distending pains of the breasts. Her red-purple tongue, thready
and weak pulse were also related to these reasons.
Western Medicine: The patient has suffered from abdominal pains
for one year, especially bilateral pains of the lower abdomen.
It became serious for one month. There were obviously pressing
pains on her abdomen, but no rebound tenderness. Her vaginal
discharge was yellow. Her menstrual flow was scant. She was
given B ultrasound examination and laparoscopy in the local
hospital as well as in Beijing for many times, and successively
she was diagnosed with bilateral annexitis, ovarian cyst of the
right side, but tubal dropsy and ovarian cyst should be
diagnosed further.
Diagnostic Differentiation:
TCM: The patient¡¯s abdominal pains should be differentiated from
stomachache. Abdominal pains are characterized by the pains of
the part below ensiform appendix, while stomachache is mainly
characterized by the pains of gastric cavity accompanied by the
symptoms of ructus, acid reflux, inappetence and etc.
Western Medicine: Chronic annexitis should be differentiated
from endometriosis. As to the two kinds of diseases, there will
be enclosed mass with pressing pains in pelvic cavity. However,
the patient suffering from endometriosis has no history of acute
infection. There is no effect after anti-inflammatory treatment.
So they are not difficult to be distinguished.
First Diagnosis:
TCM: 1. Abdominal pains
2. Hydroncus
Symptom identification: Damp-heat brewing, qi stagnation and
blood obstruction
Western Medicine: 1.Chronically bilateral annexitis
2. Ovarian cyst of the right side
3. Tubal dropsy and ovarian cyst
should be diagnosed further.
Plans for treatment strategy and nursing:
1. Routine
care of traditional Chinese internal medicine.
2. Grade
II care.
3. Common
diet.
4. Herbal
tea (to clear heat, transform dampness, dispel stasis and
dissipate the binds): one dosage a day and drink twice.
Main herbs used in herbal tea: baishao (white
peony root), baizhu (ovate atractylodes root), ezhu (zedoary)
and 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 felt abdominal pains for one year, especially
bilateral pains of the lower abdomen. There were obviously
pressing pains on her abdomen, but no rebound tenderness. Her
vaginal discharge was yellow. She had scant menstrual flow and
the period lasted about 2-3 days. During the period, she felt
the pains of the waist and abdomen. She had the symptoms of
distending pains of the breasts and dry mouth during and after
the period. Her diet, urine and bowel movement all were normal.
Her tongue coating was yellow and slightly slimy. Her tongue was
red-purple. Her pulse was thready and weak. She was given B
ultrasound examination and laparoscopy in the local hospital as
well as in Beijing for many times, but the findings were
different. There were lumps in her breasts and she could feel
pressing pains.
First diagnosis:
TCM: 1. Abdominal pains
2. Hydroncus
Western Medicine: 1. Chronically bilateral annexitis
2. Ovarian cyst of the right side
3. Tubal dropsy and ovarian cyst
should be diagnosed further.
TCM treatment strategy: Clear heat, transform dampness, dispel
stasis and dissipate the binds.
Prescription: baishao (white peony
root), baizhu (ovate atractylodes root), ezhu (zedoary) and etc.
3 dosages in total.
Date: Nov. 26, 2008 Time:
9: 00 a. m.
The patient complained
distending pains of the breasts. There were lumps in the breasts
with pressing pains. The doctor believed that she had
hyperplasia of mammary glands. The examinations of blood R, the
function of the liver and kidneys and E4A all were
normal. Continue to take the same prescription.
Date: Nov. 27, 2008 Time:
9: 00 a. m.
There were lumps in her breasts. The size of the lump in her
right breast was 4¡Á3 cm and that of her left breast was 3¡Á2 cm
with obviously pressing pains. Professor Zhang believed that she
had hyperplasia of mammary glands. She felt the pains of her
lower abdomen had lessened. The prescription was changed a
little.
Date: Nov. 30, 2008 Time:
9: 00 a. m.
The patient felt abdominal pains, so she was given the
examinations of B ultrasound and CT in the local hospital as
well as in Beijing and was diagnosed with chronically bilateral
annexitis, ovarian cyst of the right side, tubal dropsy and
bilateral mastitis. But the findings were different. In order to
make precise diagnosis, our experts suggested her take further
examinations such as B ultrasound or MRI, but she refused to do
it. Today she had menstruation, so the prescription was changed
as follows: danpi (moutan root bark),
gancao (licorice root), yujin (curcuma tuber) and etc. 3 dosages
in total.
Date: Dec. 5, 2008 Time:
9: 00 a. m.
The pains on her breasts obviously lessened. Today she nearly
had no menstruation. She also felt the pains of her abdomen had
some improvement. The previous prescription was changed a
little.
Date: Dec. 10, 2008 Time:
9: 00 a. m.
Last night she felt pains of the left upper abdomen and had the
symptom of vomiting due to having cold drink and taking
different kinds of food. The patient felt better after taking
the herbal product orally. But there were paroxysmal pains of
her abdomen, so the patient took some medicine and the pains
gradually lessened. However, there were slightly pressing pains
on the left upper abdomen. The Professor made some adjustment on
the basis of the former prescription. 3 dosages in total.
Date: Dec. 12, 2008 Time:
9: 00 a. m.
The pains of her upper abdomen basically disappeared. The pains
of her breasts obviously lessened. The lumps became smaller than
before, but there were pressing pains. The pains of the lower
abdomen had some improvement, but there were obviously pressing
pains. Continue to take the same prescription of Dec. 5 to have
further observation.
Date: Dec. 16, 2008 Time:
9: 00 a. m.
The patient said that her condition had significant improvement.
She continued to take 2 dosages herbal tea and decided to leave
the hospital on Dec. 19 with taking 2 months herbal tea for
further treatment.
¡¡
