Brief Summary: On Sep. 13, 2010, Mohammad, from The United Arab Emirates, who had suffered from stomach pain and lumbar pain accompanied by belching of gas for three year, was hospitalized in our hospital. He had achieved significant improvement after 17 days TCM treatment here.

 

 Record of Hospitalization

Name: Mahammad                                                                                                Sex: Male

Age: 55                                                                                                                 Marital Status: Married

Nationality: The United Arab Emirates                                                                  Date of Admission: Sep. 13, 2010

Complainer: The patient himself

 

First Medical Record

Date: Sep. 13, 2010                                      Time: 14: 00 p. m.

Mohammad, a 55-year-old male, had suffered from stomach pain and lumbar pain accompanied by belching for three year. He was hospitalized in our hospital for treatment at 14: 00 p. m. on Sep. 13, 2010.

Essentials for Diagnosis:

1. The patient had suffered from stomach pains accompanied with burning sense in the stomach and belching for 3 years and lumbar pains for 2 years.

2. 3 years ago, the patient began to feel stomach pains with burning sense in the stomach. At that moment, he often belched. A year later, the lumbar pains began, and it hurt when he pressed the waist. Meanwhile, he also suffered from insomnia, astriction, hot sense in the soles and palms in the night, loss of appetite, bitter taste in the mouth and sometimes sweating at night. He often feels tired and angry. He had the history of cardiovascular expansion two years ago.

3. T 36.3≧,  R 20 times/minute,  P 70 times/minute,  BP 120/80mmHg.

4. He grew normally with common nutrition and had natural expression. His mind was clear. His body was in a positive posture and he was cooperative with clear mind.

5. No thoracic deformity. Eyes' action was flexible. Thyroid was normal. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Cardiac rhythm was regular. Heart border was a little irregular. Sound of blood vessel is normal. Heart beat was 70 times/minute.

6. The abdomen was soft. There wasn't sound of pathological gastric motility. No enlargement of liver and spleen. Gall bladder was no swelling. No Mcburney's point tenderness. Tongue was red with thin greasy tongue coating. The pulse was a little floating.

7. The patient had no food allergy or drug allergy.

8. Report of electrocardiogram: sinus rhythm, and the myocardial infarction was not ruled out. No accessory examination.

Diagnostic Basis:

TCM: The patient had suffered from stomach tenderness accompanied with burning sense in the stomach and belching. There were pains on the waist with the feeling of pulling down. The main symptoms leaded to the diagnosis of stomach pain and lumbar pain,

Western Medicine: The patient had suffered from stomach tenderness accompanied with burning sense and belching. There were pains on the waist, too.

Diagnostic Differentiation:

TCM (Traditional Chinese Medicine): The patient's stomach pain should be differentiated from cardialgia. To the cardialgia, painful part is the middle and the lower part of the chest. However, stomach pain happens at the abdomen accompanying with belching. So they are not difficult to be distinguished.

Western Medicine: The disease could be tested by B ultrasound examination and Cholecystitis phase.

First Diagnosis:

TCM (Traditional Chinese Medicine): stomach pain and lumbar pain

Symptom identification: liver qi invading the stomach, obstruction of vessel and network by dampness-cold.

Western Medicine diagnosis: gastritis and lumbar pain

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Common diet.

4. TCM strategy: Course the liver and resolve depression, and tonify spleen and clear the fire, and free the network vessels.

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: Sep. 14, 2010                                      Time: 10: 00 a. m.

The patient had suffered from stomach pain and lumbar pains accompanied by burning sense in the stomach and sometimes belching and lumbar tenderness for 3 years. Meanwhile, he had the symptoms of insomnia, loss of appetite, frequent feeling of tiredness and upset, bitter taste in the mouth, hot sense in the soles and palms, sweating and frequent urination at night, floating pulse, and red tongue with greasy coating. Professor Zhang believed that he had suffered from stomach pains and lumbar pain due to liver qi invading the stomach, obstruction of vessel and network by dampness-cold. The belching was caused by ascending counter-flow of stomach qi. Obstructed cold-dampness inflew network vessels, which was the reason of lumbar pains. So the treatment strategy was to course the liver and resolve depression, tonify spleen and clear the fire, and free the network vessels. The prescription was as follows: zhuru (bamboo shavings), chaihu (bupleurum root),  baizhu (ovate atractylodes root ), etc. 3 dosages in total.

 

Date: Sep. 16, 2010                                       Time: 9: 00 a. m.

According to the feedback, there was much improvement as to the stomach pains, belching and burning sense in the stomach. But there were no changes to lumbar pains. The tongue coating was getting light, and the mouth was not so bitter.

 

Date: Sep. 22, 2010                                       Time: 9: 00 a. m.

The patient complained sharp pains on the twist with tenderness. It's hard to him to turn over. The tongue was red, but its coating was white and slippery. The pulse was floating.

 

Date: Sep. 24, 2010                                       Time: 9: 00 a. m.

The symptom of lumbar pains was reduced. But the patient was vexed and suffering from insomnia.

 

Date: Sep. 29, 2010                                       Time: 9: 00 a. m.

His spirit was good. The symptoms of lumbar pain and stomach pain disappeared, so did belching. The patient can move the body normally. To consolidate the improvement, the patient decided to take 60-day dosages with him when leaving.