Brief Summary: On Feb. 11, 2015, Zeng Dingmei, came from Zhongfang County, who had been suffering from repeated cough with phlegm and shortness of breath for more than 10 years and being severe for 10 days. She was hospitalized in our hospital. She recovered completely after 8 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization

Name: Zeng Dingmei                        Sex: Female

Age: 48                                             Marital Status: Married

Nationality: China                            Date of Admission: Feb. 11, 2015

Companion: Alone

First Medical Record

Date: Jan. 10, 2015         Time: 11:00 a.m.

This 48-year-old woman had been suffering from repeated cough with phlegm and shortness of breath for more than 10 years and being severe for 10 days. She was hospitalized in our hospital as a patient with bronchitical asthma for TCM treatment at 9:00 a.m. on Feb. 11, 2015.

Essential for Diagnosis:

1. The patient had been suffering repeated cough with phlegm and shortness of breath for more than 10 years, and her condition was severe for 10 days. There was no medical history of tuberculosis. She had no allergy history of any medicine. Yet she had the allergy history of Shrimp.

2. When the patient came to our hospital, she had the following symptoms, such as chest oppression, cough with phlegm, shortness of breath, palpitations and poor appetite. Her cough and shortness of breath was related with the weather. If the weather was cold, her condition will be worse. If the weather was warm, her condition will be relieved. Sometimes she had headache, while with no dizziness. Her urination and bowel movement were normal. 

3. T: 36.5°C   R: 20 times/minute    P: 76 times/minute   BP: 100/60 mmHg

The patient had normal spiritual status with chronic painful facial expression. The tongue body was dark purple. Her neck was soft. She had barrel chest. Sound of breathing in the lungs was low, without rhonchi. The heart rate was regular, the rhythm of her heart was 76 times per minute. Her abdomen was soft with no pressing pains and distension. There was no edema over her lower limbs. There was no pathological reflection. The tongue coating was thin and white. The pulse was wiry and weak.

4. Examination: The result showed that she had bronchitical disease and inflammation. She had bronchitical asthma and emphysema.

Diagnostic Differentiation:

TCM: Cough, asthma, distending lungs

Western Medicine diagnosis: 1. Bronchitical asthma

2. Chronic obstructive pulmonary disease, and acute severe D stage, emphysema

3. Coronary heart disease