The patient was successfully treated for acute sinusitis and ear pain using herbal medicine.
July 2015
Male, 38
Brief Synopsis Of History Taken At Visit:
The patient reported 4 day history of nasal discharge, facial pressure, and chest discomfort. The pain began after water became trapped in his ear while swimming. As per the patient, the nasal discharge is profuse in quantity with a yellow color. There was also a productive cough with phlegm. In addition the patient reports “pressure” in his cheeks, temples, and ears. The patient notes a history of sinus infections typically treated with antibiotics in the past.
Pulse: thin, choppy
Tongue: Large, moist, no coat, pink/red in color, puffy sides
TCM Diagnosis: Bi Yuan
Herbal Treatment:
-Herbs Are Granules Of 5x Concentration
8 Scoops, 2 x Day for 3 days(1g of granules approx. equals 5g of raw herb).
Xin Yin Hua Chai Hu
Cang Er Zi Huang Qin
Bai Zhi Zhi Ban Xia
E Bu Shi Cao Sheng Jiang
Chuan Xiong Zhe Bei Mu
Zhi Shi Jie Geng
Yi Yi Ren Huang Lian
Results:
Follow up 3 days later
The patient reported that while his frontal sinuses had improved greatly that the ear pain and pressure had increased and the patient felt that he might have an ear infection on his left side. As per patient he is experiencing some hearing disturbance on his left side. Pt. reports L sided gum inflammation as well. Pt. is not feverish but tends to run warm. On exam, pt. has submandibular lymph nodes present, approx. 1 – 1.5 cm, soft, slightly tender. Pulse: Wiry, Moderate Force
The following herbs were given in granules, and the patient was instructed to contact myself , his primary care, or ENT if the hearing problems worsened.
Herbs Are Granules Of 5x Concentration (1g of granules approx. equals 5g of raw herb).
10 Scoops, 2 x Day for 4 days. Total Daily Granule Dosage:
Chai Hu .5g Xuan Shen 3g
Huang Qin (Jiu) 2g Sheng Di Huang 3g
Huang Lian 1.5g E Bu Shi Cao 1g
Long Dan Cao .75g Bai Zhi 1g
Ban Lan Gen 2g Xin Yi 1g
Lian Qiao .5g
Jin Yin Hua 1g
Shi Chang Pu 2g
Zhu Ru .75g
Follow up 15 days later
The patient reported that he took the herbs as directed and that the ear pressure had resolved. The gum inflammation it turned out was due to a tooth that needed extraction.
Overall, the sinusitis and ear pain cleared over a week period.
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