Brief Summary: On March. 14, 2015, Zhang Yun, came from Huaihua city, who had been suffering from breast pains for 6 years and being severe for 2 years. She was hospitalized in our hospital. She achieved some improvement after 14 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization

Name: Zhang Yun                           Sex: Female

Age: 34                                           Marital Status: Married

Nationality: China                          Date of Admission: Mar.14, 2015

Companion: Alone

First Medical Record

Date: Mar. 14, 2015                   Time: 14:00 p.m.

This 34-year-old woman had been suffering from breast pains for 6 years and being severe for 2 years. She was hospitalized in our hospital as a patient with cystic hyperplasia of breasts for TCM treatment at 10:30 a.m. on Mar. 14, 2015.

Essential for Diagnosis:

1. The patient said she was easy to irascibility. 6 years ago she had breast distending pains. In the NO. 1 People Hospital she was found breast glands lobular hyperplasia with color Doppler ultrasound. She got the treatment, yet there was no obvious improvement. In recent years, she also got some TCM treatment and massage, her condition was stable. 2 years ago, there were the white secretions flowing out of her breasts when the patient made the massage. There were the black and brown secretions flowing out of her right breast. In October 14 of 2013, she went to the Xiangya Hospital to make a test for her breasts. She was diagnosed with cystic hyperplasia of breasts. The both of breasts had nodules. And the bilateral axillary lymph node was visible. She took the treatment yet there was no improvement. The patients wanted the TCM treatment, she came to our hospital for TCM treatment.

2. When the patient came to our hospital, there were pains over her breasts. There were white and brown secretions flowing out of her breasts. And there was skin itching, yet there was no erythema. After exercises, she felt palpitations. There were muscle pains and stiffness over her neck, shoulders and her waist. It was difficult to lift her left arm. There was slight movement limitation over her neck. Her spirit and her appetite were good. Her urination and bowel movement were normal. She had medical history of chronic urticaria for 4 years, neck and shoulders syndrome for more than 3 years. There was no allergy history of any medicine or food.

3. T: 36.4°C   R: 20 times/minute    P: 90 times/minute   BP: 110/60 mmHg

4. The patient had normal spiritual status with chronic painful facial expression. She looked tired. There was no sign of yellow sclera or yellowish skin, yet with scratches. There was no enlargement over her superficial lymph node. Her head and the five sense organs were normal without deformity and masses. The pupils were round and approximately equal in size. The pupillary reaction to the light was sensitive. There was no enlargement over her thyroid. Her neck was soft. The jugular vein was of no engorgement. There were pressing pains. And the muscle of her neck and shoulders was stiff. Sound of breathing in her lungs was clear with no any rhonchi. Rhythm of her heart was 90 times a minute. Heart rate was regular. Her abdomen was soft without pressing pains and rebound tenderness.  There was no sign of deformity over her spin and four limbs. The result of meningeal irritation sign was negative. There was no pathological reflection. The tongue body was reddish with thick coating. The pulse was wiry and weak.