Hiatus Hernia 食管裂孔疝

食管裂孔疝

2018.6.8 女  67岁

胸骨后面（膻中穴）痛第三天，由原来痛2-3分，很快发展到5-6分，不吃饭也痛，向两侧放射。前天夜里痛得不能睡，必须坐起来。咳嗽、深呼吸、吞咽东西都痛。患者以为食道癌。昨天向下发展到心口，即喷门。

曾有胃部不适、烧心、反酸等症状。但最近未发。

建议服血府逐瘀汤大剂，药后汗出、嗜睡，无寸效。

患者心、肺、乳房均正常。一个月前血压偏高，达到179/93, 75。 但中药治疗后近一周稳定在145/70，66左右。考虑这个部位除了食管没有其他东西，肯定不是胃和喉管，因为没有肺的症状。不是胸骨本身，食管裂孔疝的可能性很大。

决定以辛温开结化痰通降为治则，结合活血化瘀。药开一副。

6.9 药喝了一次，痛大减。夜里睡得很好。早上，几乎没有痛感。早饭、午饭时仍有较轻痛感。嘱续服。去做B超。

6.11 有反复，夜里痛4/10， 烦躁。

6.12 去医院检查，医生开出CT检查单，不是B超。怕病人做不必要的射线受伤，遂放弃。继续服药。

6.13 痛减至2-3分，吃饭时痛，但可坚持，不影响食欲。睡前痛一小时很轻，夜里未痛，睡好。至此，病人已经知道快要好了，精神压力没了。

6.13 除了吃饭稍有感觉，一天未痛。精神、食欲均好转。

6.16 病人来电话，说从14好下午服了地三服药之后，知道今天没有再痛,吃饭时也没有痛。只是食欲稍差。可能需要等几天恢复。嘱服完第四服药后，可以停止治疗。希望不会有反复。

因为上面提到的原因，影像没有做，所以没有西医诊断。

6.8.2018 Female 67 years old

The patient complained chest pain for three days, behind the sternum, located in the middle between breasts, and occasionally feels radiating pain to both sides. The pain increases when swallow food or drink, even cough and deep breath. Otherwise, it’s ok. I thought it was blood stagnation and issued a formula. After the herbal pills, no improvement. Instead the pain increased from 2-3 to 5-6 out of 10. At night she had to sit up for hours due to the pain. The pain is so weird, and the patient thought it might be cancer of Esophagus.

The patient has normal heart and lung function; breasts are normal but had stomach pain and reflux last month. Because of the location of the problem, I assumed it was Hiatus Hernia. A formula for one doze of herbs, simply to deplete the phlegm and disperse stagnancy.

6.9 After taking the herbal tea once at 7:00pm yesterday, the patient called today and said no pain after the herbs and last night had a good sleep. But still felt minor pain at breakfast and lunch.

I told the patient go to hospital to get an Ultrasound B Examination while taking the herbal tea, just in case I was wrong in diagnosis.

6.12 B/P 156/70, 62. The doctor ordered a CT exam. I refused because I don't want my patient who is already too weak get more X-ray. So, the patient didn't do the exam.

6.13  B/P 145/70, 66 Much less pain, only felt 2-3/10 when eating, otherwise no pain at all. Appetite is better. Till now the patient completely relieved from stress.

6.17 The patient called today saying no pain at all since 6.14 afternoon after starting taking the 3rd dose， even when eating, only the appetite was not as good as before. I told the patient just finish the 4th dose in the next few days and we can stop treatment. Because the reason I mentioned above, there is no diagnosis from the WM doctor due to not doing the imaging exam