Brief Summary:
Mr. Roca,
from Austria, who had been suffering from easily
catching cold, nasal-blocking as well as loss of
smell in traditional Chinese medicine (TCM) for 15
years, was hospitalized in our hospital on March 8,
2011. He achieved significant improvement after
almost one month TCM treatment with the help of
herbal tea, acupuncture, massage, etc.
Record of
Hospitalization
Name:
Roca Sex:
Male
Age:
29 Marital
Status: Unmarried
Nationality:
Austrian Date of
Admission: Mar. 8, 2011
Companion:
Alone
First
Medical Record
Date:
Mar. 9, 2011 Time:
10:00 am
This
29-year-old gentleman had been suffering from easily
catching cold, nasal-blocking as well as loss of
smell for 15 years. His condition sometimes became
worse, and then there appeared a toxic symptom over
his whole general body. The patient was hospitalized
in our hospital for TCM treatment at 19:00 am on
Mar. 8, 2011.
Essential
for Diagnosis:
1. The
patient had been suffering from easily catching
cold, nasal-blocking as well as loss of smell for 15
years. His condition became worse when the climate
changed worse or when he was being attacked by cold.
2. The
patient had complained of easily catching cold 15
years ago, and sometimes his condition became worse
with the appearance of toxic symptom over his whole
general body. He had heavy nasal blocking and
coughing when he spoke. He did not take any special
treatment or examination in any hospital.
3. When the
patient was hospitalized in our hospital, he had
heavy nasal blocking, easily-catching cold and loss
of smell, with occasional coughing. He did not have
phlegm. His nasal mucosa showed hyperemia and edema.
The lymph gland in his throat was two degrees
enlargement. The lymph follicle was swelling
evidently. He did not suffer from fever. His pulse
was floating. His tongue coating was thin and
yellow.
4. T:
36.4¡ãC R: 20 times/minute P: 80 times/minute
5. His spirit activity was good. He
grew normally. His diet was of common nutrition. He
had fine sense. He spoke with nasal blocking. The
lymph gland in his throat was two degrees
enlargement. There was no distention of jugular
vein. His abdomen was normal, and it was soft when
pressed. There was no enlargement on his liver and
spleen. His four limbs grew normally. He did not
feel bitter in his mouth. He liked to drink warm
water. Stool and urination were normal.
Diagnostic Basis:
TCM:
The patient had his lymph gland in his throat of two
degrees enlargement. The lymph gland was dark red.
The lymph follicle was swelling evidently. He had
nasal blocking with loss of smell. There was obvious
fester point in his throat. He coughed occasionally
with no phlegm. He sometimes felt dryness in his
mouth and liked to drink warm water. When the
climate changed and became cold, his condition
became worse, then. His tongue coating was thin and
slightly yellow. His pulse was floating. So,
according to TCM, his condition could be diagnosed
as common cold.
Western
Medicine:
His lymph gland in his throat was of two degrees
enlargement, with dark red color. The lymph follicle
was swelling. He also had nasal blocking with loss
of smell. There was obvious fester point in his
throat. He coughed occasionally with no phlegm. He
sometimes felt dryness in his mouth and liked to
drink warm water. From the view of western medicine,
his condition could be diagnosed as chronic
infection in the part of nose and throat.
Diagnostic Differentiation:
TCM: The
patient¡¯s condition should be differentiated with
nasal sinusitis. The symptom of nasal sinusitis is
turbid nasal discharge with nasty smell, while the
common cold has no nasty smell of the nasal
discharge. There are pressing pains on superciliary
ridge of the nasal sinusitis, while the patient did
not have such symptom. So, it was easy to
differentiate them.
Western
Medicine: His
condition should be differentiated from lower
respiratory tract infection. When people suffer from
lower respiratory tract infection, they usually
cough a lot and have chest pains, while the
condition of the patient did not show these
symptoms. So, it was easy to differentiate them.
First
Diagnosis:
TCM:
Common cold.
Symptom
identification: the non-diffusion of defensive
exterior and stagnation of qi and blood.
Western
Medicine: nasal
sinusitis and enlargement of lymph gland of the
throat.
Treatment
strategy and nursing:
1. Routine
care of traditional Chinese internal medicine.
2. Grade
¢ò
care.
3. Warm diet
and water.
4.
Pathogenesis: the non-diffusion of defensive
exterior and stagnation of qi and blood.
5. TCM
strategy: clearing heat and
diffusing the lungs, resolving the exterior and
resolving toxin as well as promoting the circulation
of blood.
6. Herbal
tea: one dosage a day and drink twice
7.
Acupuncture and massage: once a day
8. Have more
medical examination if necessary.
Date: Mar.
9, 2011 Time:
10:00 am
This morning, Professor Yang Qingzhi
paid a visit to the patient. The patient complained
of nasal blocking and loss of smell. He spoke with
nasal sound. The lymph gland of his throat was of
two degrees enlargement. His nasal mucosa showed
hyperemia and edema. He sometimes coughed with no
phlegm. He felt occasional dryness in his mouth and
liked to drink warm water. His condition became
worse when the climate changed worse. His tongue
coating was thin and white with slightly yellow
color. His pulse was floating and slightly feeble.
Professor Yang thought, according to the symptoms of
the tongue and pulse, the patient suffered from
chronic infection in his nasal and throat regions,
due to the non-diffusion of defensive exterior and
stagnation of qi and blood.
Therefore, the treatment should be
clearing heat and diffusing the lungs, resolving the
exterior and resolving toxin as well as promoting
the circulation of blood.
Date: Mar.
11, 2011 Time:
10:00 am
The patient
said he vomited after drank the herbal tea half an
hour or two hours later, due to the coldness and
bitterness of the herbs. So, the doctor made some
changes on his formula.
Date: Mar.
12, 2011 Time:
10:00 am
The patient
said the changed formula was easy for him to drink
the herbal tea. He felt some deduction in his cold.
Date: Mar.
15, 2011 Time:
10:00 am
The patient
said his cold improved a lot, and his nasal blocking
almost disappeared. His appetite also changed much
better. His tongue coating was thin and yellow and
his pulse was slightly floating.
Date: Mar.
20, 2011
Time: 10:00 am
The patient said he had recovered
from cold with no nasal blocking. His appetite was
normal now. His pulse was normal. His tongue was
slightly red with white tongue coating.
Date: Mar. 25,
2011 Time:
10:00 am
The patient¡¯s symptom of cold
improved evidently. Therefore, continued the former
formula.
Date: Mar. 28,
2011 Time:
10:00 am
The
patient¡¯s condition changed better, but his nasal
mucosa was a little red. His tongue was slightly red
with thin tongue coating. His pulse was normal.
Date: Mar.
30, 2011
Time: 10:00 am
Roca¡¯s
condition improved greatly than he came to our
hospital. The patient decided to leave the hospital
today. After TCM treatment in our hospital for 23
days, he had recovered from cold. He no longer had
nasal blocking. The lymph gland in his throat was
smaller a little bit than before, with light color.
The lymph follicle was smaller also. His pulse was
normal now while before it was floating and slightly
feeble.
Doctor¡¯s
advice after leaving hospital:
1. Avoid
wind-cold, take care of cold.
2. Take 60
days herbal medicine back for continuing treatment.
3. Keep away from smoking and wine,
and take light diet. ¡¡
