Sex: Male

Age: 37  

Current residence: Wuchang District, Wuhan City, Hubei Province

Summary of medical history:

Patient on 1-27-2020 Fever appeared

2/4 lung CT suggests viral pneumonia, Outpatient home treatment 

Positive nucleic acid test on February 14, Coronavirus (Covid-19) pneumonia confirmed

2/15 admitted to Fang Cang (temporary) hospital

2/23 review nucleic acid test positive

2/25 and 2/27 review nucleic acid negative twice

3/2 discharged from Fang Cang hospital and entered quarantine

The nucleic acid tests of 3/11 and 3/13 were negative both times. 

3/15 ended isolation.

(In China, patients are discharged from the hospital if their nucleic acid tests are negative twice in a roll; then they need to be quarantined for 14 days. Only if both nucleic acid tests are negative after the 14-day quarantine, the patients are considered to have completely recovered)

性别：男   年龄：37岁   现住：湖北省武汉市武昌区

病史概要：患者于2020-1-27出现发热，4/2肺部CT提示病毒性肺炎，在家治疗，2月14日核酸检测阳性，确诊冠状病毒肺炎，15/2入方舱医院治疗，23/2复查核酸阳性，25/2和27/2两次复查核酸阴性，2/3出方舱医院，进隔离点，11/3和13/3两次复查核酸检测均阴性。15/3结束隔离。

患者既往病史：无特殊。

Patient's previous medical history: unremarkable

2月3日初诊

患者诉：1月27日出现发热，2天后热退，1月31日开始出现腹泻及乏力，现在有轻微咳嗽，伴乏力、恶心欲吐，食欲不佳，有腹泻，无发热，无口干口苦，无其他不适。

初诊时治疗：达菲，盐酸莫西沙星片及莲花清瘟胶囊

Feb. 3rd, initial visit

Patient complaint: Fever began on January 27. The fever then dropped after 2 days; diarrhea and fatigue began on January 31, and now he has a slight cough with fatigue, nausea and retching, poor appetite, diarrhea, no fever, and no dry or bitter mouth, no other discomfort.

Treatment at initial diagnosis: Tamiflu, Moxifloxacin hydrochloride tablets and Lotus Qingwen capsules

Lotus qingwen capsule is a patent medicine use for viruses.

Lián qiáo, jīnyínhuā, guǐ máhuáng, chǎo kǔ xìngrén, shígāo, bǎnlángēn, mián mǎ guàn zhòng, yú xīng cǎo, guǎng huò xiāng, dàhuáng, hóng jǐng tiān, bòhé nǎo, gāncǎo.

It has a strong antiviral effect. It is cold in nature, and seems to modulate Nitric Oxide production when it’s too high.

(Niu, Q. Q., et al. "Efficacy and safety of Lianhua Qingwen capsule for influenza: a systematic review." (2017): 1474-1481.)

舌苔图片：Tongue picture

  

中药处方：

藿香15g

厚朴5g

半夏10g

杏仁10g

白豆蔻10g

生薏仁10g

苏叶10g

生谷芽15g

柴胡10g

桔梗10g

生姜10 g    

5剂 ，嘱少量频服，药物不宜久煎，少量多次服用。治疗期间饮食禁忌：忌生冷、油腻、滋腻，忌食复、劳复、房复。（备注：2月5日晚上才开始遵医嘱服药）

Chinese Medicine Herbal Prescription:

Huo xiang 15g

hou po 5g

Ban Xia 10g

Xing ren 10g

Bai dou kou 10g

Sheng yi ren 10g

Zi su ye 10g

sheng gu ya 15g

Chai hu 10g

Jie geng 10g

Sheng jiang 10g

5 doses, 

Directions: A small amount should be taken frequently. 

The herbs must not be decocted for a long time. It’s better to decoct a small amount multiple times. (To protect the volatile oils) 

Dietary prohibitions: Avoid cold (raw), greasy, sweet and over-nutritious food; stick to simple foods with bland flavors, avoid over eating, over working and fucking too much. (note: Only on the evening of February 5th did the patient begin taking the medicine as directed)

2月4日人民医院肺部CT提示病毒性肺炎

February 4th People's Hospital lung CT showed viral pneumonia

  CT Photo：

 

2月5日：患者家属述：仍然恶心想吐，腹泻4-5次，明显乏力，咳嗽频率增多，无发热。February 5: Family members of the patient reported: nausea and retching, diarrhea 4-5 times a day, obvious fatigue, increased cough frequency, no fever.

（备注：患者2月5日晚上才开始遵医嘱服药）Patient began taking herbs on the evening of February 5th.

服药前舌象照片

Tongue pic before using herbs：

 

嘱患者所开之中药每2小时一次

Instructed to take herbs every 2 hours，Every time100-150ml，maintain observation

建议停用西药。Suggested to stop using the western medicine.

2月6日：患者家属述：昨日夜间咳嗽重，晨起后减轻一些，仍有乏力，食欲差，腹泻4-5次，无发热。

February 6: Family members of the patient stated: Coughing was heavy last night. After getting up in the morning, he had some relief. He still had fatigue, poor appetite, 4-5 diarrhea, and no fever.

Tongue picture：

 

中药处方：

杏仁10g，桔梗10g，冬瓜仁20g，法夏10g，

苇茎15g，薏苡仁15g，旋覆花10g，前胡10g，

厚朴10g，白芷5g，苏叶10g，白蔻仁10g，

川芎5g，板蓝根5g，藿香15 g,生姜10g  5剂 嘱少量频服 药物不宜久煎

Chinese Herbal Medicine Prescription:

Xìngrén 10g, jiégěng 10g, dōngguā rén 20g, fǎ Ban xià 10g, wěi jīng 15g , yìyǐ rén 15g , xuán fù huā 10g , qián hú 10g, hòu pǔ 10g , báizhǐ 5g , sū yè 10g, báikòurén 10g, chuānxiōng 5g , bǎnlángēn 5g, huò xiāng 15 g , shēngjiāng 10g

5 doses, take small amount frequently. Herbs can’t be cook for long.

2月7日 患者家属述：仍咳嗽，昨日起出现头昏，仍有恶心，腹泻次数减少，无呕吐，无发热。嘱继续服药，至夜间诉：自我感觉好转，食欲好转，仍有点头昏，腹泻4次。

2月9日：患者家属述：咳嗽稍好转，腹泻好转，4次/天，精神状态明显好转，食欲明显好转，无发热，无口干，无其他不适。

February 7 The family of the patient stated: still had coughing, dizziness since yesterday, still had nausea, diarrhea decreased, no vomiting, no fever. Instructed to continue taking medicine.

Complaints in the night: self feeling better, better appetite, still a little dizzy, and diarrhea 4 times.

February 9: Family members of the patient reported: Cough improved slightly, diarrhea improved, 4 times / day, mental state improved significantly, appetite improved significantly, no fever, no dry mouth, and no other discomfort.

Tongue Pics：

  

2月10日：患者家属述：偶咳嗽，无腹泻，无其他不适。

2月12日：患者家属述：昨日出现喉咙痛，今日疼痛消失，咳嗽进一步减轻。

February 10: The patient's family stated: Occasional cough, no diarrhea, and no other discomfort.

February 12: Family members of the patient stated: Sore throat appeared yesterday, the pain disappeared today, and the cough was further alleviated.

Tongue pic：

 

2月13日，核酸检测阳性，复查胸部CT提示肺部炎症病变范围明显缩小。

On February 13, the nucleic acid test was positive, and reexamination of chest CT showed that the scope of lung inflammation was significantly reduced

CT Report：

 

2月14日，患者家属诉：咽喉不适，基本无咳嗽。核酸检查阳性，入方舱医院治疗。

On February 14, the patient's family members reported a sore throat and no cough. The nucleic acid test was positive, and he was admitted to the Fang Cang (temporary) hospital.

Tongue Pic：

 

2月22日，患者家属诉：入方舱医院后继续服用院内的中药肺炎1号方治疗，现情况良好，无不适，今日复查胸部正位X线片提示肺部无异常。

On February 22, the family of the patient reported that after entering the Fang cang Hospital, he continued to take the traditional Chinese medicine pneumonia formula No. 1 in the hospital. The condition is now good and there is no discomfort. Today's chest X-ray examination showed no abnormalities in the lungs.

 

3月2日，患者两次复查核酸阴性，出院，入隔离点。

The patient was negative for nucleic acid twice and was discharged from the hospital and admitted to quarantine

3月15日，患者在隔离点两次复查核酸阴性，结束隔离。

The patient reviewed the nucleic acid negative twice at the isolation point and ended the isolation