Brief
Summary:
On Dec. 7, 2008, Nedyalka, from Bulgaria, who has suffered from
hyperplasia of mammary glands and distending pains of the
breasts for one year, was hospitalized in our hospital. She has
achieved obvious improvement after 42 days TCM treatment here.
Record of Hospitalization
Name: Nedyalka Birthplace: Bulgaria
Sex: Female Profession: Lawyer
Age: 40 Nationality: Bulgaria
Marital Status: Married Onset
season: Heavy snow
Date of Admission: Dec. 7, 2008 Date of
Record: Dec. 7, 2008
Complainer: The patient herself
First Medical Record
Date: Dec. 7, 2008 Time:
1: 00 a. m.
Nedyalka, a 40-year-old female, has suffered from distending
pains of the breasts for one year. She was hospitalized in our
hospital for treatment at 1: 00 a. m. on Dec. 7, 2008.
Essentials for Diagnosis:
1.
The patient has suffered from distending pains of the breasts
for one year.
2. Last
year, the patient felt distending pains of the breasts without
obvious reasons, especially the outer side of the breasts.
Compared with the right breast, the distending pains of her left
breast were more serious. When she had menstruation or her
emotion was fluctuant, it became more serious. She felt mouth
dry and was fond of drinking warm water. She was shortsighted.
Sometimes she had headache, pains of the left shoulder and
waist, slight swelling of her eyelids, fingers and ankle. Her
urine was normal. But she had constipation and comparatively
profuse menstruation.
3. T
36.2¡æ,
P 81 times/minute, R 20 times/minute, BP 120/80 mmHg.
4. She
grew normally with common nutrition. Her mind was clear. She had
natural complexion and an expression of chronic illness. 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. Apex beat was
normal. Heart border was normal. Heart beat was 81 times/minute.
Cardiac rhythm was regular. No pathological murmurs on
auscultation.
6. There
were enclosed masses in the outer side of her breasts with
slightly pressing pains. The edges of the enclosed masses were
clear. There were no pressing pains and rebound tenderness on
her abdomen. She had red-tipped tongue and yellow tongue
coating. Her pulse was floating and wiry.
7. Accessory
examination: B ultrasound examination showed that she had
hyperplasia of mammary glands, hysteromyoma and ovarian cyst.
Diagnostic Basis:
TCM: The patient has suffered from distending pains of the
breasts for one year, especially the outer side of the breasts.
Compared with the right breast, the distending pains of her left
breast were more serious. When she had menstruation or her
emotion was fluctuant, it became more serious. Her menstruation
flow was comparatively profuse. There were enclosed masses in
the outer side of her breasts with slightly pressing pains. So
it was not difficult to be diagnosed with mammary aggregation.
Western Medicine:
1. The
patient has suffered from distending pains of the breasts for
one year.
2. There
were enclosed masses in the outer side of her breasts with
slightly pressing pains.
3. B
ultrasound examination showed that she had hyperplasia of
mammary glands, hysteromyoma and ovarian cyst.
Diagnostic Differentiation:
TCM: The patient¡¯s mammary aggregation should be differentiated
from mammary rock which mainly occurs in 40-60 years middle and
old aged female. The course of disease is short and the onset of
the disease is quick. The lumps in the breasts are very hard
like stones and the surface of the lumps is uneven. The edges of
the lumps are not clear and the flexibility of those is not
good. There are no pressing pains and conscious pains in an
early stage. So they are not difficult to be distinguished.
Western Medicine: Hyperplasia of mammary glands should be
differentiated from mastofibroma. Both of the diseases will
result in lumps of the breasts. As to mastofibroma, the lumps
mostly can be found on one side of the breast. Usually there are
no distending pains of the breasts or there is only slight
discomfort of the breasts during the period without pains. The
patients are mostly under 30. However, if one suffers from
hyperplasia of mammary glands, usually there are distending
pains of the breasts before the period and the patient can feel
the pains when the lumps are touched. Moreover, the size of the
lumps of the breasts will be different with the changes of the
period. So they are not difficult to be distinguished.
First Diagnosis:
TCM: Mammary aggregation
Symptom identification: Constrained liver qi, qi stagnation and
blood stasis.
Western Medicine: 1. Hyperplasia of mammary glands
2. Hysteromyoma
3. Ovarian cyst
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: Course the liver, rectify qi, quicken the
blood, transform stasis and dissipate the binds.
5. Herbal
tea: one dosage a day and drink twice.
Main herbs used in the herbal tea: Chaihu (bupleurum
root), chishao (red peony root), chuanniuxi (cyathula root),
etc.
6. Acupuncture
and massage: once a day.
7. Have
more medical examinations if necessary.
Date: Dec. 8, 2008 Time:
8: 40 a. m.
The patient has suffered from
distending pains of the breasts for one year, especially the
outer side of the breasts. Compared with the right breast, the
distending pains of her left breast were more serious. When she
had menstruation or her emotion was fluctuant, it became more
serious. She felt mouth dry and was fond of drinking warm water.
She was shortsighted. Sometimes she had headache, pains of the
left shoulder and waist, slight swelling of her eyelids, fingers
and ankle. Her urine was normal, but she had constipation. The
result of physical examination was as follows: T 36.2¡æ,
P 81 times/minute, R 20 times/minute, BP 120/80 mmHg. There were
enclosed masses in the outer side of her breasts with slightly
pressing pains. The edges of the enclosed masses were clear.
There were no pressing pains and rebound tenderness on her
abdomen. She had red-tipped tongue and yellow tongue coating.
Her pulse was floating and wiry. According to her condition,
Professor Zhang believed that she had mammary aggregation due to
constrained liver qi, qi stagnation and blood stasis. So the
treatment strategy is to course the liver, rectify qi, quicken
the blood, transform stasis and dissipate the binds.
Date: Dec. 9, 2008 Time:
8: 40 a. m.
The patient didn¡¯t complain about her headache. Her sleep was
good. Her urine and bowel movement were normal. There was no
symptom of swelling in recent two days. She felt slight pains of
her waist. Today there were obvious distending pains of the
outer side of the left breast. The feedback of today¡¯s
examinations was as follows: Blood R showed WBC 13.6¡Á109/L.
Mid. Gran was a little high. Urine R showed RBC 0-1/HP, WBC
1-3/HP, and occult blood +1. The patient didn¡¯t feel obvious
discomforts. Maybe she had urinary
tract infection, so the doctor added some herbs to clear heat,
resolve toxin and disperse inflammation. 4 dosages in total.
Date: Dec. 13, 2008 Time:
8: 40 a. m.
Her condition was basically stable. She felt the distending
pains of the outer side of the breasts had lessened. Continue to
take the former prescription. 4 dosages in total.
Date: Dec. 17, 2008 Time:
8: 40 a. m.
Her condition was basically good. There were no pains and the
symptom of swelling all over the body. Her urine and bowel
movement were normal. There were pressing pains in the outer
side of her breasts, but the size of the enclosed masses became
smaller. She didn¡¯t feel the burning sense. Her tongue was pale.
Her tongue coating was thin and white. Her pulse was thready and
wiry. The doctor adjusted the prescription to quicken the blood
and dissipate the binds as follows: baizhi (angelica
root), xiangfuzi (cyperus root), chishao (red peony root) and
etc. 4 dosages in total.
Date: Dec. 20, 2008 Time:
8: 40 a. m.
Today she had menstruation. The distending pains of the breasts
before the period obviously lessened. The others were normal.
The feedback of today¡¯s examinations was as follows: Blood R was
normal. Urine R showed RBC 2-4/HP and occult blood + 1. The
prescription was changed a little. 4 dosages in total.
Date: Dec. 25, 2008 Time:
8: 40 a. m.
Today she had no menstruation. The distending pains of her
breasts disappeared for 2 days. The patient didn¡¯t complain
about other discomforts. Continue to take the same herbal tea. 6
dosages in total.
Date: Dec. 28, 2008 Time:
10: 00 a. m.
There were no distending pains of her breasts. Her diet and
sleep both were normal. The patient didn¡¯t complain about any
discomforts. Tomorrow she would be given B ultrasound
examination of ovary, uterus, adnexa and galactophore.
Date: Dec. 29, 2008 Time:
10: 00 a. m.
She didn¡¯t complain about the distending pains of her breasts.
Her diet and sleep were normal. Continue to take the same
prescription of Dec. 17. 3 dosages in total.
Date: Jan. 3, 2009 Time:
9: 00 a. m.
The patient didn¡¯t complain about any discomforts. The
prescription was changed a little. 4 dosages in total.
Date: Jan. 7, 2009 Time:
9: 00 a. m.
Her sleep was good. Her urine and bowel movement were normal.
Today she felt pressing pains of the outside part of her left
breast. The others were normal. The pressing pains were the
normal reaction because the doctor added some herbs to quicken
the blood, dissipate the binds and free the network vessels. So
the prescription was the same as Jan. 3. 3 dosages in total.
Date: Jan. 10, 2009 Time:
9: 00 a. m.
All her condition was normal. Continue to take the former
prescription. 7 dosages in total.
Date: Jan. 17, 2009 Time:
9: 00 a. m.
She decided to leave the hospital tomorrow.¡¡
