Brief Summary: On Jan. 26, 2015, Mr. Zeng Xianliang, came from the countryside near our hospital, who had been suffering acute exacerbation of chronic bronchitis 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 bronchitis and infection.