Brief Summary:
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 Å 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.
