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Abstract: The patient in this case is a 45-year-old middle-aged woman who felt pain and discomfort in her throat 1 week ago, but did not seek medical attention, and came to our outpatient clinic only after her symptoms did not improve after taking anti-inflammatory drugs at home. After one month of treatment with a combination of Chinese and Western medicine, the discomfort disappeared and all the tests were abnormal.
Basic information】Female, 45 years old
Disease Type】Chronic nasopharyngitis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Time of consultation】August 2014
Treatment plan】Intravenous drip (penicillin sodium for injection) + nebulized inhalation (budesonide suspension for inhalation)
Treatment period】1 month of treatment with medication
Treatment effect] The disease was cured and the painful throat disappeared.
I. Initial consultation
The patient is female, 45 years old. 7 days ago, she felt pain and dryness in the throat, no fever, no cough and sputum, no headache and dizziness, no nausea and vomiting, and no choking and coughing when eating. He was treated at home with anti-inflammatory drugs (name and specific dosage of the drugs are not known), but the effect was not good. He came to our hospital today, and outpatient examination showed chronic congestion of the mucous membrane of the pharynx, no enlargement of the tonsils bilaterally, lymphatic follicle hyperplasia, an ulcerated surface of about 0.2 cm in diameter in the right hypopharynx, and a cyst of about 0.3 cm × 0.3 cm × 0.2 cm in size in the left pharynx, soft to touch, no pain, and not easy to bleed. With the above findings and symptoms, the patient was initially diagnosed with chronic nasopharyngitis and admitted to our department for treatment.
II. Treatment history
The patient was anxious at first and was afraid of the disease. After I introduced the causes of the disease, as well as the treatment plan and treatment effect to her in detail, her mood gradually improved and she agreed to undergo drug treatment after discussing with her family. In response to the patient’s condition, a treatment plan combining Chinese and Western medicines was adopted. Sodium penicillin for injection was given as an intravenous anti-inflammatory treatment, and budesonide suspension for inhalation was used to relieve nasal discomfort by nebulized inhalation.
III. Treatment effect
After 1 week of drug treatment, the patient’s dryness and pain in the pharynx were reduced compared with those before the visit, and the pharyngeal mucosal congestion and edema were also relieved by re-examination of laryngeal dynamic microscopy. The inflammatory factors such as IL-1β and interleukin-5 were at normal levels. After stopping the drug for six months, there was no further attack.
IV. Precautions
After a period of treatment, the patient’s condition was controlled and the discomfort in the throat basically disappeared, and the patient’s mood was getting better and better. At the same time, I instructed the patient and his family to pay attention to the patient’s psychological condition because chronic nasopharyngitis has a long course and is prone to recurrence, although the symptoms have improved, to avoid the patient’s recurrence of the disease to increase the psychological pressure, which will affect the treatment. This can lead to aggravation of the disease.
V. Personal insight
Chronic nasopharyngitis is a common chronic disease of the ear, nose and throat, which has a long treatment period, and because there is no specific performance at the beginning of the disease, it is easy to be ignored by patients, so it also makes treatment more difficult. So the key to its treatment is to go to the hospital in a timely manner after the abnormal symptoms of the throat, and follow the doctor’s instructions for continuous medication, while during treatment to pay attention to diet regulation, after treatment, but also to do a good job of personal protection to avoid catching cold, cold, increasing the chances of recurrence of chronic nasopharyngitis.