Brief Summary: On March 31, 2015, Ms. Chen Jinmei, came from the countryside near our hospital, who had been suffering from repeated cough and chest oppression for more than 10 years, being severe for 3 days. She was hospitalized in our hospital. She got some improvement after 8 days TCM treatment with herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization

Name: Chen Jinmei                                                    Sex: Female

Age: 53                                                                     Marital Status: Married

Nationality: China                                                     Date of Admission: March 31, 2015

Companion: Alone

First Medical Record

Date: Mar. 31, 2015

The patient has had repeated cough and chest oppression for more than 10 years, and being severe for 3 days. She was hospitalized in our hospital as a patient with acute exacerbation of chronic bronchitis. She was hospitalized in our hospital for TCM treatment at 9:00 a.m. on Mar. 31, 2015.

Essential for Diagnosis:

1. Medical History: The patient had been suffering from repeated cough and chest oppression for more than 10 years, being severe for 3 days. There is no tuberculosis history. There was no allergy history of any food or medicine.

2. When Ms. Chen Jinmei came to our hospital for treatment, she had the following symptoms such as, chest oppression, chest pains, cough with scanty phlegm, shortness of breath, dry throat and headache and aversion to cold. Her appetite and sleeping were not good. There was no obvious fever or night sweat. Her urination or bowel movement were normal.

3. T: 37.2     P: 80 times/minute   R: 22 times/minute    BP: 110/80mmHg

4. The patient had normal growth, physique and spiritual status. She had chronic sick facial complexion. She cooperated with doctor when the physical examinations were made. There were no signs of yellow sclera or yellowish skin. There were two lymph node enlargement near her jaw. Her neck was soft with no resistance. She could turn her neck flexibly. There were large swelling and hyperemia sign over her throat. There is no enlargement over her thyroid gland. Her trachea was good and in the center. Her chest was symmetrical. Sound of breathing in the lungs was bigger, with a few of rhonchi. Rhythm of her heart was 80 times per minute. Heart rate was regular with no murmurs. Her abdomen was soft, without any pressing pains, rebound tenderness or enclosed mass. There was no sign of deformity over her spine. There were no other pathological reflections. Her tongue was reddish with yellow coating. Her pulse was thin and wiry.

Primary Diagnosis:

TCM: Cough

Western Medicine diagnosis:

1. Acute exacerbation of chronic bronchitis

2. Chronic pharynx cough

Treatment strategy and nursing:

1. Routine care of TCM, grade II care, common diet.

2. To apply for the three routine inspection, and the following related examination: function of the kidneys and liver, IMX, anti-O, ESR, RF, myocardial enzyme, 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: Apr. 01, 2015           Time: 10:00 a.m.

Dr. Zhu Ming, doctor-in-charge, paid a visit to the patient this morning. This 53-year-old woman had been suffering from repeated cough, chest oppression with scanty phlegm and shortness of breath for more than 10 years. Because of the climate change her condition was getting worse for 3 days. In recent days, she had the following symptoms such as, chest oppression, chest pains, cough with scanty phlegm, shortness of breath, dry throat and headache and aversion to cold. She had poor appetite and dry throat. Her throat was red and swelling. Sometimes she had cough with scanty phlegm and stuffy nose. It affected her sleeping. Her urination and bowel movement were normal. Her tongue was reddish with yellow coating. Her pulse was thin and wiry.

　

Date: Apr. 04, 2015           Time: 9:00 a.m.

The vital signs of the patient were stable. The spirit status of the patient was better. The patient said the cough, chest oppression, phlegm and the shortness of breath improved obviously. And the pains over her throat obviously relieved. Her appetite and sleeping were better. Her urination and the bowel movement were normal. Compare with before, the sound of breathing in the lungs was clearer. The tongue was red with teeth mark. And the tongue coating was thin and yellow. To take the same formula.

　

Date: Apr. 08, 2015           Time: 9:00 a.m.

The vital signs of the patient were stable. The patient said the cough almost disappeared, and the discomfortable sensation of her throat improved greatly. Her breath was good and smooth. Her appetite and sleeping were good. The sound of breathing in the lungs was clear. And the lymph nodes around her throat disappeared. Her tongue coating was thin and white. The patient decided to leave our hospital today. The doctor suggest her to take the herbal medicine back for consolidating the effect.