Brief Summary: On Jan. 26, 2015, Mr. Zeng Xianliang, came from the countryside near our hospital, who had been suffering acute exacerbation of chronic bronchits and infection. He was hospitalized in our hospital. He got some improvement after 7 days TCM treatment with herbal tea, acupuncture and massage in our hospital.

 

Record of Hospitalization

Name: Zeng Xianliang                                              Sex: Male

Age: 68                                                                   Marital Status: Married

Nationality: China                                                  Date of Admission: Jan. 26, 2015

Companion: Alone

　

                                     First Medical Record

Date: Jan. 26, 2015

The patient has had cough and itching throat for 2 months, and expectoration for 8 days. He was hospitalized in our hospital as a patient with acute exacerbation of chronic bronchitis and infection for TCM treatment at 11:30 a.m. on Jan. 26, 2015.

Essential for Diagnosis:

1. Medical History: The patient had been suffering cough, itching throat for 2 months, and expectoration for 8 days. The patient had hypertension for 12 years. There is no allergy history of any food or medicine. The patient has suffered from chronic bronchitis for 5 years.

2. When Mr. Zeng Xianliang came to our hospital for treatment, he had the following symptoms such as, cough with white phlegm, especially at night. He had dry mouth and itching throat. He preferred to cold drink. There were pains over his manubrium. And the pains became worse when he coughed. Sometimes he had palpitations without heart pains and difficult breathing. Occasionally he had shortness of breath. He was easy to get a cold usually. Sometimes he had dizziness, headache and tinnitus. There was difficult swallowing without nausea and vomiting. Sometimes he had back pains. And he had sweating over his upper body. His lower limbs were of aversion to cold. The night urination was 1 to 2 times. The color of urine was yellow without burning sensation. His appetite was good, while his sleeping was not good. His urination and bowel movement were normal.

3. T: 36.5     P: 72 times/minute   R: 20 times/minute    BP: 180/100mmHg

4. The patient had normal growth, physique and spiritual status. He cooperated with doctor when the physical examinations were made. There were no signs of yellow sclera or yellowish skin. There was no enlargement over his superficial lymph nodes. His neck was soft with no resistance. His trachea was good and in the center. His throat was slightly red, but with no pains. And there was no enlargement over his thyroid. His chest was symmetrical. Sound of breathing in the lungs was bigger, without any rhonchi. Rhythm of his heart was 72 times per minute. Heart rate was regular with no murmurs. His abdomen was soft, without any pressing pains, rebound tenderness or enclosed mass. There was no sign of deformity over his spine. The meningeal irritation was negative. There were no other pathological reflections. His tongue was reddish with white and thin coating. His pulse was thin and wiry.

5. Examination: X-ray, the results showed he had acute exacerbation of chronic bronchits and infection.

Primary Diagnosis:

TCM: Cough

Western Medicine diagnosis:

1. Acute exacerbation of chronic bronchitis and infection

2. Hypertension

Treatment strategy and nursing:

1. Routine care of TCM, grade II care, low fat, low salt diet.

2. To apply for the three routine inspection, and the following related examination: function of the kidneys and liver, blood sugar, blood fat, myocardial enzyme, electrocardiogram, etc.

3. Herbal tea: one dosage a day and drink twice.

4. Acupuncture and massage: once a day

5. Avoid wind and cold, regulate living timetable, open mind, take care of diet.

　

Date: Jan. 27, 2015                     Time: 9:00a.m.

Dr. Luo Jundong, doctor-in-charge, paid a visit to the patient this morning. This 68-year-old man had been suffering from cough and itching throat for 2 months, and expectoration for 8 days. He was hospitalized in our hospital as a patient with acute exacerbation of chronic bronchitis and infection for TCM treatment at 11:30 a.m. on Jan. 26, 2015. When Mr. Zeng Xianliang came to our hospital for treatment, he had the following symptoms such as, cough with white phlegm, especially at night. He had dry mouth and itching throat. He preferred cold drink. There were pains over his manubrium. And the pains became worse when he coughed. Sometimes he had palpitations without heart pains and difficult breathing. Occasionally he had shortness of breath. He was easy to get a cold usually. Sometimes he had dizziness, headache and tinnitus. There was difficult swallowing without nausea and vomiting. Sometimes he had back pains. And he had sweating over his upper body. His lower limbs had aversion to cold. The night urination was 1 to 2 times. The color of urine was yellow without burning sensation. His appetite was good, while his sleeping was not good. His urination and bowel movement were normal. His tongue was reddish with white and thin coating. His pulse was thin and wiry.

　

Date: Jan. 28, 2015                         Time: 9:00 a.m.

The patient said the cough at night relieved obviously. And the pains over his manubrium obviously improved. There were no pains over his throat, but it was still itching. His tongue body was reddish with white and thin coating. His pulse was thin, wiry and rapid. To take the same formula.

　

Date: Jan. 29, 2015                         Time: 9:00 a.m.

The patient said he had choking after drinking water, it continued for about 8 minutes. And then the choking relieved. There were no pains over his manubrium and no itching over his throat. He felt discomfort of his abdomen. There was distension sensation over his abdomen. His appetite was good. And his urination and bowel movement were normal. The results of test showed: ALT 56↑; cl 105.8↑; TG2.03 ↑; LDL 4.32↑; NEVT 0.33↓; LYMPH 92.5↑; MONO 0.30↓; EOS 0.4↓; MCV 102.8↑; PLT 75.00↓; RDW-SD 5.71↑; PDW 20.2↑. This morning the doctor adjusted the formula.

　

Date: Jan. 31, 2015                         Time: 9:00 a.m.

The patient said that he still have distension sensation over his abdomen without nausea and vomiting. His bowel movement was normal. Checked his bowel sound, it was 3 to 4 times per minutes. His abdomen was distending, without enclosed masses. There were slight pains over his liver when the doctor pressed, but with no rebound tenderness. Doctor suggested him to take a B ultrasound over his liver, gallbladder, pancreas, spleen and  kidneys.

　

Date: Jan. 31, 2015                         Time: 14:00 p.m.

The results of B ultrasound showed that the patient had fatty liver.

　

Date: Feb. 01, 2015                          Time: 9:00 a.m.

The patient said he still had cough, especially at night. Yet the phlegm reduced. And there were no pains over his manubrium and his back. His dizziness and headache both relieved greatly.  

　

Date: Feb. 01, 2015                          Time: 14:00 p.m.

The patient decided to leave our hospital tomorrow. The cough and itching throat had obvious improvement. And there were no pains over his manubrium. Considering the patient had hypertension and fatty liver, the doctor suggest him to take the herbal medicine back for continuing treatment.

Doctor’s advice after leaving hospital:

1. Avoid wind-cold, regulate living timetable.

2. Maintain good moods

3. Take care of diet, do not take cold and spicy foods.