2015, Szilagyi, came from Romania, who suffered from tumor behind his right ear
On Feb. 07, 2015, Szilagyi, came from Romania, who suffered from tumor behind his right ear and this tumor grew fast. He found it on September, 2014. He was hospitalized in our hospital. He had great improvement after 25 days TCM treatment.
Record of Hospitalization
Name: Szilagyi Sex: Male
Age: 65 Marital Status: married
Nationality: Romania Date of Admission: Feb. 07, 2015
Companion: his wife
First Medical Record
Date: Feb. 07, 2015 Time: 14:00 pm
This 65-year-old man had been suffering from tumor behind his right ear for 5 months. The patient was hospitalized in our hospital for TCM treatment at 11:00 p.m. on Feb. 07, 2015.
Essential for Diagnosis:
1. On Sep-2014, the patient found one tumor behind his right ear and this tumor grew fast. After several inspections, while the character of this tumor still did not confirmed. The details of the tumor as below: large tumor on his neck position, dia-2.5cm, transverse dia: 2.8cm-3.5cm, and almost covered all over the whole of his right neck position, irregular boundary of the tumor, unsmooth surface and bad mobility. The patient suffered from skin cancer on outer side of lower right leg in 2010.By surgical excision and skin grafting of the lower right leg, the cancer of this part of body was under controlled. It did not progressed and was not deteriorated.
2. When the patient came to our hospital, the diameter of the tumor was 2.5cm and the transverse diameter was 2.8cm to 3.5cm. The tumor almost covered all over his right neck. It was of irregular boundary, unsmooth surface and bad mobility. There was no enlargement over his superficial lymph node. The movement of the neck was normal. When on left lying position, the patient felt the oppression sensation on the neck. His sleeping was good without sweating. And his bowel movement and urination were normal. The color of urine was slightly yellow.
3. T: 36.5°C R: 20 times/minute P: 66 times/minute BP: 140/90mmHg
4. The patient had normal growth and normal spiritual status. Yet the patient had chronic painful facial expression. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. His ears were normal without discharge, and his hearing was normal. The bilateral mastoid has no pressing pains. His nose was normal, there was no stuffy nose and discharge. His lips were slightly red. There were no congestion in his throat and no enlargement over his tonsil. The thyroid was normal. His trachea was symmetrical, as well as his chest. The jugular vein was of no engorgement. Sound of breathing in the lungs was clear, without any rhonchi. The interatrial septum was narrow. Rhythm of his heart was 85 times per minute. Heart rate was regular with no murmurs. His abdomen was soft with no pressing pains and rebound tenderness. His left knee was sore, and the ability of walking up and down stairs and bending his knee were limited. The meningeal irritation was negative. There was no pathological reflections, but the physiological reflections existed. His tongue body was dark purple. The pulse was deep and tart.
5. In the local hospital, the patient did the test, there was no sign of cancer, yet the size of tumor was large.
Diagnostic Basis:
TCM: Phlegm-damp obstruction
Western Medicine: Tumor but it was not confirmed.
Treatment strategy and nursing:
1. Routine care of traditional Chinese internal medicine.
2. Grade Ⅱ care.
3. Light diet, avoid wind and cold, have a good mood and take care of diet.
4. Complete the related examination
5. Herbal tea: one dosage a day and drink twice
6. Acupuncture and massage: once a day
Date: Feb. 07, 2015 Time: 15:00 p.m.
Doctor Zhu Ming paid a visit to the patient. The patient suffered from the tumor behind his right ear. The diameter of tumor was 2.5cm and the transverse diameter was 2.8cm to 3.5cm. The tumor almost covered all over his right neck. It was of irregular boundary, unsmooth surface and bad mobility. There was no enlargement over his superficial lymph node. The movement of the neck was normal. When on left lying position, the patient felt the oppression sensation on the neck. His sleeping was good without sweating. And his bowel movement and uriation were normal. The color of urine was slightly yellow. There were no other symptoms.
Date: Feb. 08, 2015 Time: 10:00 a.m.
The patient said he had good sleep. There was no obvious difference with his pulse. To be seen.
Date: Feb. 09, 2015 Time: 10:00 a.m.
The patient said the symptoms were almost the same. The color of urine was slightly yellow. Doctor adjusted the formula. And the results of test were normal.
Date: Feb. 12, 2015 Time: 10:00 a.m.
The patient felt discomfort over his tumor. But the body temperature was normal. And the patient condition was stable, so doctor decided to keep the same formula.
Date: Feb. 14, 2015 Time: 10:00 a.m.
The patient said the movement of his neck was improved. The temperature was normal.
Date: Feb. 17, 2015 Time: 10:00 a.m.
The vital signs of the patient were stable. There was no discomfort. And the blood pressure was normal.
Date: Feb. 2, 2015 Time: 10:00 a.m.
The patient said the tumor was obviously softer than before. The large tumor was separated to several small lymph nodules. The pulse was deep and slow. His eating and sleep were normal.
Date: Feb. 24, 2015 Time: 10:00 a.m.
The patient said the tumor was softer and softer. The condition was improved.
Date: Feb. 28, 2015 Time: 10:00 a.m.
The tumor became smaller obviously.
Date: Mar. 03, 2015 Time: 9:00 a.m.
The patient decided to leave our hospital today. The size of the tumor was reduced 1/3.
Doctor’s advice after leaving hospital:
1. Avoid wind-cold, maintain good mood, and take care of diet, keep doing exercises.
2. Take herbal medicine back for continuing treatment.