2014, Noura, from Egypt, who had suffered from repeated discomfort and foreign body sensation

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 Ⅱ 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

The patient decided to leave our hospital today. After 40 days TCM treatment, the patient recovered. All the abnormal symptoms were gone.