Hubei Hospital of Traditional Chinese Medicine
Name Xxx Gender Female Age xx Medicare number X-ray No. xxx
Hospitalization Date xxx, 2015 Hospital No. xxx CT No. xxx
Discharge Date xxx, 2015 Total days 24 MRI No..--
Conditions in admission:
The patient: Xxx, female, 37 years old, married, "anal prolapse mass with pain for more than 8 months, severe for one day", and be admitted to hospital from the clinic as "mixed hemorrhoids with thrombosis". Admission observation: clear and spirited, obvious anal prolapse mass, difficult todefecate, with anal pain and discomfort, anal bleeding during defecating this morning, with a lot of volume and color red, low back pain and discomfort, defecate every 1-2 days with normal quality, smooth urine, normal eat and drink, general sleeping quality. Specialist examination: visible tumor prolapsesat 1-11 point of anal lithotomy position, visible edema at 9-11 point of prolapse, hard, dark color and tenderness, finger examination and anoscope are not available cause of patient’s fear of pain.
Admission diagnosis:
TCM diagnosis:
Hemorrhoids
Damp syndrome
Western Medicine Diagnosis:
Mixed hemorrhoids with thrombosis
Special laboratory findings: blood clotting, blood, ECG: normal; HBsAg negative; liver function blood: no obvious abnormalities; CT: protrusion to the rear of discs of waist-4 and lumbar-1; lumbar spine bone hyperplasia. Chest: X-ray of chest showed no abnormal.
During treatment: on xxx, underexternal cavity barrier ridge vent anesthesia of hard outer shell, perform mixed hemorrhoid ligation within surgery + sclerotherapy hemorrhoids +anal nipple resection + fissure nipple resection,after successful surgery, perform anti- infection, end bleeding and symptomatic treatment with anal herbal fumigation, microwave therapy and medication treatment.
Discharge conditions: defecate 1-2 times a day with normal quality, no mucus stool blood, smoothurine, normal eating, drinking and sleeping. Physical examination: clear, gently breathing and spirited, flat wound, the edema of wound edge subside nearly, drainage unobstructed, fresh granulation, no significant bleeding exudate. According to the patient's condition and requirements, apply for discharge.
Discharge diagnosis:
TCM diagnosis:
Hemorrhoids
Damp syndrome
Western Medicine Diagnosis:
Mixed hemorrhoids with thrombosis
Analnipple hypertrophy
Fissure
Discharge Instructions:
1. Outpatient follow-up, consult if unconformable
2. Regular dressing to keep the wound clean.
3. Avoid spicy food to keep the stool.
4. Further lumbar treatment after hospital discharge.
Physician Signature:
Date: February 17, 2015
Hubei Hospital of Traditional Chinese Medicine
8-3 Ward
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