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Case Study of Acid Regurgitation

 

by Dr. Li-Chuan Hsu & Dr. Zi-Huei Lin

Center for Traditional Chinese Medicine, China Medical University Beigang Hospital

 

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Case Report

[Patient Information]

 

[Chief Complaint]

Acid regurgitation with a burning sensation for one month. She vomited on 10/01/2008 (one day before her initial visit.)

 

[History of Present Illness]

The patient is a 70-year old female. She had been having a poor appetite for one month and an urgency to vomit when she smelled food. She suffered immediate vomiting of ingested foods along with the symptoms of acid reflux. She vomited again on 10/01/2008, therefore she came to our Chinese Medicine department for treatment on 10/02/2008.

 

[Past History]

Hypertension (under good control with medication), diabetes (under control with medication), cardiac disease (She had cardiac catheterization and stent implantation surgery at Chia-Yi Christian Hospital on 10/08/1997. She is taking medication), asthma (She is taking medication), and both knees had replacement surgery.

 

[Personal History]

 

[Examinations (Four Diagnostic Methods of Chinese Medicine)]

Inspection Examination

Build: Slightly thin

Complexion: Dark black

Nails: Slightly red

Skin: Lots of stasis spots underneath the skin

Hair: Thin

Eyes: Blood vessels can be seen in the white of the eyes; slightly turbid

Mouth and Lips: Pale lips with stasis color

Tongue: More pale with a white coating

Listening and Smelling Examination

Smell: No special smell when breathing or on the body

Voice: She panted when talking; her voice was hoarse, low and weak

 

Inquiry Examination

Cold and Hot: Cold extremities

Sweat: Frequent spontaneous sweating

Head and Face: Frequent headache

Urination and BM: She had hard stools usually and had no strength to expel them. She needed to take stool softener to help BM. She had one BM/day when taking stool softener. 2~3 times nighttime urination, yellow color.

Digestion: Immediate vomiting of ingested foods, poor appetite

Drinking: She favored hot drinks

Nose: Normal

Throat: No discomfort

Ear: No abnormal hearing

Mouth and Teeth: No discomfort

Chest: Occasional chest dull pain when her cardiac disease attacked

Abdomen: No discomfort

Trunk: Easy to have sore achy low back

Limbs: Had surgical removal of bumps at left wrist so she’s having unsmooth grabbing. Both knees had replacement surgeries at Chang Gung Hospital

Emotions: Easy to feel nervous

Sleep: Hard to fall asleep but slept fine after falling asleep

Energy: Acceptable

 

Palpation Examination

Pulse: (Left) Cun: faint; Guan: faint, choppy when pressed deep; Chi: faint

          (Right) Cun: faint; Guan: Slightly tight with Qi counterflow feeling; Chi: faint

Palpation: Cold extremities

 

[Western Medicine Physical Examination]

General: Height: 150cm Weight: 47Kg

Vital Signs:

Temperature: 36.3°C

Heart Rate: 98/min (10/02/2008), 106/min (10/13/2008), 98/min (10/27/2008)

Blood Pressure: 131/68 mmHg (10/02/2008), 137/69 mmHg (10/13/2008), 132/71 mmHg (10/27/2008)

Breath Rate: 21~24/min

 

HEENT:

Head: Normal exterior

Eyes: Blood vessels seen in sclera; slightly turbid

Conjunctiva: Slightly turbid exterior

Eyelids: Normal

Eyesight: Normal, had cataract surgery

Ears: Normal exterior, no abnormal secretions

Nose: Normal exterior, no abnormal secretions

Throat: Normal exterior

Neck and Shoulder: Hard to lift right arm

Chest: Normal exterior

Abdomen: Normal

Lower Back: She mentioned she had bone spurs so her back is fre­quently sore and achy. She did not suffer scoliosis.

Limbs: Both knees have had replacement surgeries. She had surgery on her left wrist. It was hard for her to lift her right arm.

 

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