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
Marital Status: Married
Date of Admission: March
First Medical Record
Date: Mar. 31, 2015
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:
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.
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.
37.2 P: 80 times/minute R: 22 times/minute BP: 110/80mmHg
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.
Western Medicine diagnosis:
exacerbation of chronic bronchitis
Chronic pharynx cough
Treatment strategy and nursing:
Routine care of TCM, grade II care, common diet.
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.
tea: one dosage a day and drink twice.
Acupuncture and massage: once a day
wind and cold, regulate living timetable, open mind, take care of diet.
Date: Apr. 01, 2015 Time: 10:00 a.m.
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
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.
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.