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Abstract: A patient with fever came to the outpatient clinic, complaining of feeling wind-cold 3 days ago, and now he has a body temperature of 37.8℃, aversion to cold without sweating, occasional headache, throat tightness, sore throat, etc. The tongue is light red, the moss is yellow and greasy, the pulse is slippery, after clinical examination combined with the tongue and moss and pulse, the TCM diagnosis is seasonal cold. After several days of treatment, the patient’s body temperature returned to normal, the symptoms of cough and phlegm disappeared, and the tongue and pulse returned to normal.
Basic information】Female, 55 years old
Type of disease】Sometimes a cold
Hospital】Xiyuan Hospital, Chinese Academy of Traditional Chinese Medicine
Consultation time】March 2018
【Treatment plan】Therapeutic treatment with TCM tonics (honey ephedra, almond, gypsum, raw licorice, jinyinhua, fishy grass, scutellaria, dandelion, zhebei, geranium)
[Treatment Period] 7 days of outpatient medication
Treatment effect] The body temperature returned to normal, the cough and phlegm disappeared, and the tongue and pulse returned to normal.
I. Initial consultation
A patient with fever, Auntie Han, came to the outpatient clinic complaining of wind chill 3 days ago, with a body temperature of 37.8℃, aversion to cold and no sweating, occasional headache, tightness in the throat and sore throat. The patient had a temperature of 38℃, a light red tongue, a yellowish coating, a smooth pulse, coarse breath sounds in both lungs, and no dry rales were heard. Ancillary tests showed positive influenza A antigen, blood count showed leukocytes 4.5×10^9/L, neutrophil percentage 57%, lymphocyte percentage 30%, and no abnormality in lung CT. According to the examination results, the diagnosis of Chinese medicine was seasonal cold and the diagnosis of Western medicine was influenza A.
II. Treatment history
Based on the patient’s symptoms of fever, chills without sweating, and pulse signs such as light red tongue, yellow greasy coating, and slippery pulse, combined with the results of routine blood tests and lung CT examinations, the patient was considered to have a seasonal cold, but no bacterial infections were combined at present, so the treatment was given with pungent, cool, symptomatic and heat-clearing tonics. The prescription included honey ephedra, almonds, gypsum, raw licorice, honeysuckle, fishy grass, scutellaria, dandelion, zhebei, and geranium. The patient’s fever subsided in 1 day and the cough and phlegm disappeared in 3 days.
III. Treatment effect
On the second day after taking the medicine, the patient’s body temperature dropped to normal. 3 days after taking the medicine, the patient’s symptoms such as cough, sputum, sore throat, headache and tightness in the back of the neck disappeared, but he was slightly weak. Before taking the medicine, the patient’s tongue coating was yellow and greasy, which was a manifestation of heat congestion in the lung, but after taking the medicine, the patient’s heat subsided and the tongue coating became thin. Before taking the medicine, the patient had a slippery pulse, but after taking the medicine, the pulse gradually became stable, and the patient was basically cured after 1 week of treatment.
IV. Notes
I am glad that the patient’s condition has improved after treatment, but he still needs to rest for a few days, and he should pay attention to the diet not to eat spicy and stimulating, too greasy food, otherwise the symptoms will be easily repeated. The symptoms of the seasonal cold are heavier than those of the common cold, and complications are likely to occur, so it is important to keep the body healthy and not to stay up late or get wet so as not to lower the body’s resistance. Patients can exercise properly after they feel no physical abnormalities, pay attention to gradual progress and choose brisk walking, jogging, etc. according to their physical condition. If patients have fever, sore throat, cough and other symptoms, they should consult a doctor in time to avoid delaying the disease.
V. Personal insight
The seasonal cold mostly occurs in autumn and winter, so pay attention to increase the clothing at the right time to avoid getting cold and having the evil of epidemics invade the body and get sick. The seasonal cold is common among men, women and children, whether they are physically fit or not, so it is important to pay attention to prevention during the epidemic period, and since the disease is a respiratory tract infection, it is important to wear a mask. If you find yourself suffering from seasonal cold, pay attention to rest, drink more water, eat lightly, but also promptly consult a doctor and treat under the guidance of a doctor.