Patient Information:

• Name: Mrs. Yu
• Diagnosis: Stomach Cold and Qi Stagnation (post-thoracolumbar spinal cord space-occupying lesion surgery)
• Date of Birth (D.O.B): July 4, 1962
• Gender: Female
• Country: China

Treatment: Moxibustion + Acupuncture (Body & Abdomen)

Medical History:
Five days post-surgery, Mrs. Yu experienced stomach cold and qi stagnation symptoms.

Medical Condition Before TCM Treatment:

• Symptoms:
  • Abdominal distension, nausea, dysphagia for 2 days
  • Cold sensation in stomach region
  • Post-surgical constipation refractory to Kaiselu & Domperidone for 2 days
  • Poor sleep quality
  • Thirst but normal urination
  • Fatigue, pale face
• Tongue: Light purple with thick, slight greasy coating
• Pulse (Liver & Spleen): Wiry

TCM Treatment for Stomach Cold and Qi Stagnation:

Moxibustion + Acupuncture (Body & Abdomen)

Medical Condition After TCM Treatment:

• Symptoms improvement after treatment:
  • Able to eat well and discharge stool on Day 1
  • Complete relief of abdominal distension by Day 3
  • Persistent fatigue with walking, stable thirst, unchanged sleep quality
• Tongue: Pale with white coating (Day unknown)
• Prescription: Seven packets of Chinese medicinal broth

Post-treatment Management:

Discharged for home rest; complete recovery.