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Abstract: A 20-year-old girl was diagnosed as having a seasonal cold because she suddenly felt wind chill. She developed a cough 3 days ago and took Lianhua Qingfei capsule on her own without any significant relief. When she came to the clinic, she presented with sore throat, cough, coughing up white sputum, and no sweating. On examination, she saw that the throat was red and not swollen, the respiratory sounds of both lungs were clear, no dry and wet rales were heard, and no significant abnormality was found on blood tests and lung CT.
Basic information】Female, 20 years old
Type of disease】Current cold
Hospital】Xiyuan Hospital, Chinese Academy of Traditional Chinese Medicine
Time of consultation】May 2018
Treatment plan】Chinese herbal medicine treatment (burdock, honeysuckle, forsythia, fenugreek, poria, fried white atractylodes, Chenpi, raw licorice, windbreak, honey aster, winter flower, zhebei, golden lotus)
Treatment Period】4 days of outpatient treatment
Effectiveness】Symptoms gradually relieved
I. Initial consultation
A 20-year-old girl came to the clinic with sore throat. She reported that she suddenly developed sore throat 1 week ago after exertion and rain, and the pain was more intense, and she felt pain when swallowing, and she had no sweat when she had cold. At the time of consultation, the patient’s symptoms included sore throat, cough, white sputum, regulated urine, loose stool, light fat tongue, thin coating, and floating pulse. On physical examination, he had a red, non-swollen pharynx, clear breath sounds in both lungs, and no dry rales were heard. Ancillary examinations revealed positive influenza A antigen, and routine blood tests showed leukocytes of 4×10^9/L, neutrophils of 55%, and lymphocytes of 35%, with no abnormalities seen on CT of the lungs. Therefore, the TCM diagnosis was cough, with evidence of wind-heat offending the surface, phlegm congestion of the lung, and seasonal cold.
II. Treatment history
The patient has a sore throat, cough, white sputum, acceptable sleep, regulated urine, loose stools, a pale fat tongue, thin coating, and floating pulse. On physical examination, he had a red and swollen pharynx, clear breath sounds in both lungs, and no dry rales were heard. No significant abnormality was found in the blood routine and lung CT. The patient was considered to have a cold and no bacterial infection was combined. Based on the patient’s symptoms and tongue and pulse, the patient was identified as having wind-heat and phlegm congestion in the lung, and treatment was based on dispersing wind-heat and strengthening the spleen to resolve phlegm. The prescription mainly consisted of burdock seeds, honeysuckle, forsythia, forsythia, poria, fried atractylodes, Chen Pi, raw licorice, antiphlogistic, honey aster, dong Hua, zhe Bei, and golden lotus.
III. Treatment effect
The patient’s symptoms of sore throat were obviously relieved after 2 days of taking the medicine, and the cough, cough and diaphoresis were relieved after 4 days of taking the medicine. Before the treatment, the patient’s tongue was light and fat, which was typical of a spleen deficiency and phlegm stagnation, but after only 4 days of treatment, the patient’s tongue was less fat and larger. Before treatment, the patient’s pulse showed a floating pulse, which is typical of lung-heat offending the surface, and after treatment, the patient’s pulse has gradually stabilized.
IV. Notes
I am glad that the patient’s symptoms of sore throat have been relieved after treatment, but the patient should still pay attention to the situation of spleen deficiency and phlegm stagnation after treatment. Since it takes some time to regulate spleen deficiency, the patient can normally consume lotus seeds, yam, barley and other medicinal food products that strengthen the spleen and stomach in moderation to gradually replenish the spleen and stomach. On weekdays, patients should strengthen physical exercise to enhance the body and its ability to adapt to climate change. Pay attention to the prevention of cold and warmth, increase and decrease clothing at the right time when the climate changes, and cautiously contact cold patients to avoid the invasion of the evil of the time, which has an important role in the prevention of colds, especially the epidemic season of the seasonal colds, prevention can generally make the incidence of colds greatly reduced.
V. Personal insight
People are generally susceptible to seasonal colds, and in this case, the patient was infected after exertion and rain. Therefore, during the season of seasonal colds, we should pay attention to protection, wear masks when going out, wash hands regularly, disinfect and keep warm. In addition, human immunity is closely related to whether or not to catch a seasonal cold, and people with strong immunity can better defend themselves against external evil, so they should pay attention to exercise and eat a light diet to nourish their spleen and stomach to avoid catching a cold.