Brief Summary:
On
Jan. 26, 2015, Mr. Zeng Xianliang, came from the countryside near our hospital,
who had been suffering acute exacerbation of chronic bronchits 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
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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
bronchits and infection.
Primary Diagnosis:
TCM:
Cough
Western Medicine diagnosis:
1. Acute
exacerbation of chronic bronchitis and infection
2.
Hypertension
Treatment
strategy and nursing:
1. Routine care of TCM,
grade II care, low fat, low salt diet.
2. To apply for the
three routine inspection, and the following related examination: function of the
kidneys and liver, blood sugar, blood fat, myocardial enzyme, electrocardiogram,
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.
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Date:
Jan. 27, 2015 Time: 9:00a.m.
Dr. Luo
Jundong, doctor-in-charge, paid a visit to the patient this morning. This
68-year-old man had been suffering from 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. 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 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 had 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. His tongue was reddish with white and thin
coating. His pulse was thin and wiry.
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Date:
Jan. 28, 2015 Time: 9:00 a.m.
The patient said the
cough at night relieved obviously. And the pains over his manubrium obviously
improved. There were no pains over his throat, but it was still itching. His
tongue body was reddish with white and thin coating. His pulse was thin, wiry
and rapid. To take the same formula.
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Date: Jan. 29, 2015
Time: 9:00 a.m.
The patient said he had
choking after drinking water, it continued for about 8 minutes. And then the
choking relieved. There were no pains over his manubrium and no itching over his
throat. He felt discomfort of his abdomen. There was distension sensation over
his abdomen. His appetite was good. And his urination and bowel movement were
normal. The results of test showed: ALT 56¡ü;
cl 105.8¡ü;
TG2.03 ¡ü;
LDL 4.32¡ü;
NEVT 0.33¡ý;
LYMPH 92.5¡ü;
MONO 0.30¡ý;
EOS 0.4¡ý;
MCV 102.8¡ü;
PLT 75.00¡ý;
RDW-SD 5.71¡ü;
PDW 20.2¡ü.
This morning the doctor adjusted the formula.
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Date: Jan. 31, 2015
Time: 9:00 a.m.
The patient said that he
still have distension sensation over his abdomen without nausea and vomiting.
His bowel movement was normal. Checked his bowel sound, it was 3 to 4 times per
minutes. His abdomen was distending, without enclosed masses. There were slight
pains over his liver when the doctor pressed, but with no rebound tenderness.
Doctor suggested him to take a B ultrasound over his liver, gallbladder,
pancreas, spleen and kidneys.
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Date: Jan. 31, 2015
Time: 14:00 p.m.
The results of B
ultrasound showed that the patient had fatty liver.
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Date: Feb. 01, 2015
Time: 9:00 a.m.
The patient said he
still had cough, especially at night. Yet the phlegm reduced. And there were no
pains over his manubrium and his back. His dizziness and headache both relieved
greatly.
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Date: Feb. 01, 2015
Time: 14:00 p.m.
The patient decided to
leave our hospital tomorrow. The cough and itching throat had obvious
improvement. And there were no pains over his manubrium. Considering the patient
had hypertension and fatty liver, the doctor suggest him to take the herbal
medicine back for continuing treatment.
Doctor¡¯s advice after
leaving hospital:
1. Avoid wind-cold,
regulate living timetable.
2. Maintain good moods
3. Take
care of diet, do not take cold and spicy foods.¡¡
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