Hospitalization Record
Name: Edwin Sanchez Gender: Male
Age: 36 years old Nationality: United States of America
Profession: Construction Height: 5.7
Weight:168 lbs. Time of Hospitalization: April 13, 2005. 10:Am
Major complaint: Inward stomach pressure for three months, much
gas accumulation inside the stomach which causes big discomfort.
Slight burning inside, radiating slight pains to the back.
No obvious reason to cause current health problem, maybe due to
slight emotional stress. One year ago, the patient felt slight
stomach pressure and was given intravenous injection to relax
the stomach muscle, the condition was gone. About three months
ago, Mr. Edwin felt inward stomach pressure happening again. In
recent five weeks, the local distention is persistent, with
intermittent burning sense. No obvious pains locally. Lots of
gas inside, many times of gas passing everyday, especially after
meal. Also there is a feature, after food intake, the distention
can be relieved. Yet, after the meal, much more gas is produced.
This can cause the back radiating pains worsened. Both too cold
and too hot drinks could worsen the feeling. No vomiting sense.
Sometimes there is acid regurgitation in a little way. Not mucus
or saliva increase in the mouth. The appetite is reduced and the
food intake is reduced about thirty percent. The discomfort area
is the upper middle abdomen. Sometimes the local part is
pulsating.
No loss of hair, no tinnitus. The eyes are sometimes dry when
waking up. No blockade or runny nose. No obvious dry lips or
mouth, but during recent four weeks, he is not thirsty but
forced himself to drink a lot. No obvious bitter taste, salty
taste in the mouth. When he is very worrisome he feels the
throat is hard to swallow foods. No chest pains or distention,
no palpitations.
In general, the middle and the lower abdomen are comfortable
without any distention or pains. The bowel movement is once or
twice a day, neither sloppy nor diarrhea. The urine is sometimes
yellowish, no frequent urination, no night urination when
sleeping. No prostate and no man¨s problems. The legs are
strong.
In the past, the emotional state is quite peaceful, so the
sleep, spirit and appetite are quite normal. During recent
weeks, the emotional state is melancholic, depressed and
worrisome. The sleep is unrest and easy to wake up, and even
shaking of the body happens sometimes. The spirit is reduced
30%. Ten pounds were lost recently.
No sweat in the daytime and at night. No aversion to cold. No
hot sense in the palms and in the soles in the afternoon. The
back is generally comfortable except this radiating pains from
stomach.
The patient made an operation in 1997 for herniated disk,
cervical vertebra No.7. No other history of diseases. The New
York hospital check by biopsy and stomach camera reveals that
there is a major ulcer at the lower part of the stomach and
three small ulcers. All other check range normally. No coughing,
no phlegm spitting. No swelling of the body.
The tongue is moist. There is much fluids inside the mouth. The
tongue coating is greasy and yellowish. The pulse is string-like
with slightly slippery.
Current Diagnosis: Western medicine: gastric ulcer
TCM: liver qi stagnation, damp heat in the stomach.
Treatment strategy: smoothing the liver qi, moving the qi,
tonifying the spleen, restraining acid, clearing heat, reducing
dampness.
bupleurum root 12g, curcuma tuber 10g, codonopsis root 15g,
ovate atractylodes rhizome 15g, Chinese yam 10g, poria 10g, amommon
10g, sausurea root 10g, cyperus root 10g, bitter orange 10g, cuttle-fish
bone 12g, blettilla 12g, wild chrysanthemum root
15g, dandelion 15g.
First two dosages for two days supply. Taking 150 to 200
milliliters each time and twice a day.
April 13, yesterday 2:00 pm, taking the first tea for 150
milliliters, no abnormal feeling. 6:00 pm for the second dosage
of tea for 200 milliliters. The stomach could accept. One hour
later, more intensive inward pressure could be felt. Twenty
percent increase of burning sense inside the stomach. 9:00,
taking very little dinner, both the burning sense and inward
pressure were not relieved. Even felt the dropping sense of the
stomach.
In the recent weeks, every two days, the patient could feel the
radiating pains to the back from due to the stomach problem,
lasting two hours each time. This feeling almost could not be
felt yesterday.
No vomiting sense, no diarrhea. This morning the appetite return
50% compared to the condition at home in the normal situation.
No bitter taste in the mouth, no sour taste in the mouth. The
gas accumulates in the stomach is reduced fifteen percent.
In the past, at home, when taking the meal, the patient may fell
very tired and sleepy and weak for half an hour. This feeling
does not happen yesterday and today.
At home, after eating the stomach pressure is reduced 80% to
90%. This breakfast makes the pressure reduced 60%
astragalus root 20g, cimicifuge 10g, bupleurum root 12g,
curcuma tuber10g, codonopsis root 15g, ovate atractylodes
rhizome 15g, Chinese yam 10g, poria 10g, amommon 10g, sausurea
10g, cyperus root 10g, bitter orange 10g, cuttle-fish bone 12g,
blettilla 12g, wild chrysanthemum root 15g, dandelion 15g.
This dosage is for April 15. Putting astragalus root 20g and
cimicifuge 10g to lift the middle qi.
April 15, 2005. Yesterday, as to the lunch and dinner, Edwin was
returning to normal appetite, feeling hungry.
Last night, the sleeping is quite calm from 9:00 Pm to 3:00 Am
this morning. The bowl movement is normal at 3:00 Am. 9:00 Pm
last night, much gas inside the abdomen, relieved after the bowl
movement.
This morning, good appetite. Now, the patient is feeling that
the inward pressure is reduced thirty percent. Compared to the
same time in America, the gas accumulation in the stomach is
reduced fifty percent. No acid or bitter taste in the mouth. No
radiating pains to the back. No dropping sense of stomach..
The urine is less yellowish. The tongue coating is less
yellowish and thinner. The liver pulse is less string-like a
little bit.
cimicifuge 10g, bupleurum root 12g, curcuma tuber 10g,
codonopsis root 15g, ovate atractylodes rhizome 15g, Chinese yam
10g, poria 10g, amommon 10g, sausurea 10g, cyperus root 10g,
bitter orange 10g, cuttle-fish bone 12g, blettilla 12g, wild
chrysanthemum root 15g, dandelion 15g. One dosage.
Since the dropping sense is not too much, so removing astragalus
root 20g. The other ingredients keep the same.
Dr. Ming
April 16, 2005, yesterday the patient took a very little walk
across the street, started getting pressure 2:20 Pm. Drank the
tea at 3:45 Pm, one hour latter, great pressure and much gas and
great radiating pains at the back. Laid down about 5:45 to 6:05,
the gas and distention and pains relieved 10%. After about three
hours, the distention, pains and much gas were gone. But no
burning sense in the stomach.
The appetite is good for dinner. Sleep is calm from ten Pm to
5:30 Am this morning. So now, the stomach feels comfortable, no
gas inside, no radiating pain, no burning sense. This breakfast,
the patient has good appetite. The tongue is still slightly
yellowish.
To remove the herbs astragalus root and cimicifuge, the first
step is to heal the ulcer. Add areca 10g inside the formula to
strengthen moving the qi.
bupleurum root 12g, curcuma tuber10g, areca husk 10g, codonopsis
root 15g, ovate atractylodes rhizome 15g, Chinese yam 10g, poria
10g, amommon 10g, sausurea 10g, cyperus root 10g, bitter orange
10g, cuttle-fish bone 12g, blettilla 12g, wild chrysanthemum
root 15g, dandelion 15g.
Dr. Ming
April 17,2005. So the general condition of Edwin is the ulcer of
stomach. And due to over-worriment of his condition, this causes
drooping down of the stomach qi. So once he walks or stand for
about 20 minutes, he feels much gas inside the stomach,
radiating pains to the back and inward pressure of the stomach.
Yesterday the appetite is good. From 12:00 to 2:00 pm, the
patient feels much gas inside the abdomen, radiating pains to
the back and inward pressure. After 2:00, all the symptoms
almost relieved without abnormal feeling.
This morning, good breakfast. Right now, no any abnormal sense.
The tongue coating is less yellowish. The bowl movement is easy
to defecate.
Put scutellaria 8g in the former formula for another day to help
clear the heat.
April 18, 2005, yesterday, the major abnormal feeling is the
back muscle pains at the superficial area. Almost no stomach
inward pressure, no gas accumulation the whole day. This
morning, good appetite for breakfast. Middle degree back pains
of muscles. The patient self feels that the inward pressure is
70% reduced. The gas accumulation is 65% reduced. No stomach
burning sense, no acid regurgitation. The stool is little bit
constipated. So put two herbal ingredients to moisten the
intestines to help deification.
bupleurum root 12g, curcuma tuber 10g, hemp seed 10 g,
codonopsis root 15g, ovate atractylodes rhizome 15g, Chinese yam
10g, poria 10g, amommon 10g, sausurea 10g, cyperus root 10g,
bitter orange 10g, cuttle-fish bone 12g, blettilla 12g, wild
chrysanthemum root 15g, dandelion 15g, bushy cherry 10g,
scutellaria root 10g.
Dr. Ming
April 19, 2005, yesterday in the morning, the patient did not
feel some abnormal feeling about the stomach, such as inward
pressure of the stomach, gas accumulation, only the back muscle
pains. After the message for 20 minutes, the pains were reduced
80%. Considering this tender point beside the vertebra is the
muscle strain or due to hard labor which damaged the old wound,
since 8 years old there was a surgical operation for this part
of vertebra.
So our conclusion that Edwin suffers three condition, stomach
ulcer, stomach qi dropping down, and old wound damage of the
back. The sleep of last night is calm.
This morning, the patient does not feel discomfort of the
stomach, such as stomach pressure, dropping sense, burning sense
and gas accumulation.
Now, if moving the arms left and right, mild pains at the former
tender point. If do not move the arms left and right, no pains.
The spirit is energetic. The complexion looks better. The tongue
coating is less yellowish.
bupleurum root 12g, curcuma tuber 10g, scutellaria root 10g,
codonopsis root 15g, ovate atractylodes rhizome 15g, Chinese yam
10g, poria 10g, amommon 10g, sausurea 10g, cyperus root 10g,
bitter orange 10g, cuttle-fish bone 12g, blettilla 12g, wild
chrysanthemum root 15g, dandelion 15g, bushy cherry 10g.
Dr. Ming
April
20, 2005, yesterday only 3:00 to 7:00, there is 30% inward
pressure of stomach, and 20% gas accumulation inside the
stomach. No back pains. Good sleep last night. The stool is
normal.
This morning, every symptom does not exist. The patient feels
very good. The tongue coating is slightly yellowish.
bupleurum root 12g, curcuma tuber 10g, scutellaria root 10g,
codonopsis root 15g, ovate atractylodes rhizome 15g, Chinese yam
10g, poria 10g, amommon 10g, sausurea 10g, cyperus root 10g,
bitter orange 10g, cuttle-fish bone 12g, blettilla 12g, wild
chrysanthemum root 15g, dandelion 15g, bushy cherry 10g, areca
husk 10g.
Dr. Zhu Ming
April 21, 2005, yesterday the stomach generally feels good, no
inward pressure of the stomach, only twenty percent gas
accumulation. Back pains medium degree for three hours. Appetite
is good, bowl movement is normal. Today, the stomach is fine.
Much gurgling sound in the abdomen, no distention, so it is good
movement of the intestines.
bupleurum root 12g, curcuma tuber 10g, scutellaria root 10g,
codonopsis root 15g, ovate atractylodes rhizome 15g, Chinese yam
10g, poria 10g, amommon 10g, sausurea 10g, cyperus root 10g,
bitter orange 10g, cuttle-fish bone 12g, blettilla 12g, wild
chrysanthemum root 15g, dandelion 15g, bushy cherry 10g, areca
husk 10g.
Dr. Zhu Ming
April 22, 2005, yesterday, the stomach generally feels fine and
comfortable. There are two hours slight gas accumulation. This
morning, good appetite. There is no inward stomach pressure and
gas accumulation. The local massage on the back helps the tender
pains a lot.
So Edwin stays in our hospital for herb tea treatment for ten
days. The clinical symptoms and suffering were relieved eighty
percent, he said.
So the final diagnosis for Edwin is gastric ulcer, spleen qi
dropping down, and old wound damage on the back.
Now, tomorrow Edwin will leave Huaihua. We suggest Edwin taking
40 days dosage back home to continue with the treatment so that
full recovery could be gained soon.
Please be careful with spicy foods, alcohol, beer and drinks
like Coca-Cola. Keep emotionally relaxed and happy. Avoid taking
up heavy articles. Massage the back for a period to relieve the
muscle strains.
bupleurum root 12g, curcuma tuber 10g, scutellaria root 10g,
codonopsis root 15g,
ovate atractylodes rhizome 15g, Chinese yam 10g, poria 10g,
amommon 10g, sausurea 10g, cyperus root 10g, bitter orange 15g,
cuttle-fish bone 12g, blettilla 12g, wild chrysanthemum root
15g, dandelion 15g, bushy cherry 10g, turmeric 10g, peach
kernel 10g.
Dr. Zhu Ming
Another case of
gastritis we treat well here.