On April 15, 2014, Noura, from Egypt, who had
suffered from repeated discomfort and foreign body sensation
over her throat for 6 years, being severe in recent 2 months,
was hospitalized in our hospital. She achieved significant
improvement after 40 days TCM treatment with the help of herbal
tea, acupuncture and massage.
Record of Hospitalization
Name:
Noura
Sex: Female
Age:
34
Marital Status: Married
Nationality:
Egypt
Date of Admission: Apr. 15, 2014
Companion:
Alone
First Medical Record
Date: Apr. 15,
2014 Time: 10:00 am
This 34-year-old lady
had suffered from repeated discomfort and foreign body sensation
over her throat for 6 years, being severe in recent 2 months.
The patient was hospitalized in our hospital for TCM treatment
at 19 pm on April 14, 2014.
Essential for
Diagnosis:
1. The patient had been
suffering from repeated discomfort and foreign body sensation
over her throat for 6 years, being severe in recent 2 months. No
allergy history to any food or any medicine.
2. When the patient
hospitalized in our hospital, he suffered discomfort and foreign
body sensation over her throat. She sometimes felt itchy over
her throat. She felt dryness in her mouth and throat. When her
condition became severe, there would be slightly pains and
burning sensation over her throat. She felt itchy over the skin
of her earflaps and sternocleidomastoid muscle. She also felt
stiff over her neck part. She felt pains over the muscles of her
whole body, especially the muscles of her thighs. Her
menstruation period was normal, with normal color and quantity.
She suffered occasional painful menstruation, without blood
clots. Appetite and sleep were good. Urination and bowel
movement were normal.
3. T: 36.4＜C R: 20
times/minute P: 72 times/minute BP: 110/70 mmHg
4. Her spirit activities
were normal.
There was no yellow skin or yellow sclera over her whole body.
There was slight enlargement over her superficial lymph node.
Her neck was soft with no resistance. There was slightly
swelling over the left part of her throat, with white membrane
covering it. Her chest was symmetrical. Rhythm of his heart was
72 times per minute. Heart rate was regular with no murmurs.
Sound of breathing in the lungs was
clear, without any rhonchi. Her abdomen was soft with no
pressing pains and rebound tenderness. Her tongue was slightly
red with slightly thick and white tongue coating. Her pulse was
deep and thready.
First Diagnosis:
TCM: 1. Acute
Tonsillitis
2. Impediment Symptom
Western medicine
diagnosis: Chronic Tonsillitis
Treatment strategy
and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade
care.
3. Companion.
4. Common diet.
5. Herbal tea: one
dosage a day and drink twice
6. Acupuncture and
massage: once a day
7. Have more medical
examination if necessary.
Date: Apr. 15,
2014 Time: 16:00 am
Dr. Ming,
doctor-in-charge, paid a visit to the patient this morning. The
patient said because she caught cold 6 years ago, she suffered
from fever and aversion of cold. However, because of improper
treatment, her condition occurred repeatedly. Then, the patient
often felt discomfort over her throat, with foreign body
sensation over it. When symptoms happened, she suffered from
fever and aversion of cold, as well as itchy skin.
Date: Apr. 16,
2014 Time: 10:00 am
There was no obvious
change over her discomfort feeling of her throat.
Date: Apr. 17,
2014 Time: 10:00 am
There was some slight
relief over the symptoms of her throat. She still felt itchy
over her skin, especially over her neck part. There was
enlargement of lymph nodes on both right and left sides of her
neck. The left side was little bigger than the right side.
Date: Apr. 20,
2014 Time: 10:00 am
The symptom of fever
over her throat still existed.
Date: Apr. 24,
2014 Time: 10:00 am
The symptom of mass over
her throat was almost gone, but enlargement of lymph nodes of
her neck still existed. Her pulse was slow and thready.
Date: Apr. 27,
2014 Time: 10:00 am
The menstruation of the
patient came. She did not feel pains or any discomfort.
Date: Apr. 30,
2014 Time: 10:00 am
It was the fourth day of
her menstruation. She did not feel any discomfort. The quantity
of her menstruation was little, but the quality was good.
Enlargement of lymph nodes of her neck still existed.
Date: May 5,
2014 Time: 10:00 am
The condition of the
patient was good. She did not feel any discomfort of her throat.
There was a slight enlargement of lymph nodes of her neck, but
smaller than before.
Date: May 10,
2014 Time: 10:00 am
The patient¨s condition
was controlled. There was no discomfort. Her pulse was slightly
wiry. Her tongue coating was thin. There was no infection over
her throat.
Date: May 15,
2014 Time: 10:00 am
The patient¨s condition
was stable. There was no enlargement of the lymph over her
throat. The enlargement of the lymph nodes over her neck was
almost gone. Food swallowing and sleep were good.
Date: May 20,
2014 Time: 10:00 am
The menstruation of the
patient came. There were no discomfort or abdominal pains.
Date: May 25,
2014 Time: 10:00 am
