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