Record of Hospitalization

Name: Mr.S                                                                           Sex: Male 

Age: 56                                                                                  Occupation: Captain 

Date of hospitalization: February 20, 2006                               Marital Status: Married 

Major complaint: lower limbs are completely paralysed for 8 years.

Disease history: 

In 1974, the patient felt that his left half-length body became numb, without any reasons and had no feelings even burning it with cigarette. He was hospitalized for a month and did not find out the cause of disease. The symptoms voluntarily vanished with no medicine after four months. In 1980, he found the skin on the surface of neck and feet was tight. He was again hospitalized in the hospital for 2 weeks and did not find out the cause of disease. After the third week he restored voluntarily normally. 

Since 1986 he could not run without reasons and could not keep balance when standing with his eyes closed. He was hospitalized again. The doctor suspected it was encephaloma, but after the further inspection, finding it was wrong. After 4 months, his feet would feel stiff and could not move if he walked over one kilometer, only could walk by pulling his feet. He was finally diagnosed with MS (multiple sclerosis). In 1987 he emigrated to Sweden because of the Iran and Iraq war, and could not walk since then. His condition aggravated day by day and needed walking stick to help walk. From 1990 he began to use the wheelchair, until 1995 his lower limbs could not move completely. Since 1998 he had to depend on the electrically operated wheelchair to move, because both hands have lost strength. The  left hand strength loss is probably 75%, the strength loss of right hand is probably 95%. Besides MS, he also has hypertension, and was compelled to retire. His condition was aggravated continuously and no knee jerk reflex, as well as twitch of waist and lower limbs. He had been taking Azatioprinnm orally for a long time so condition was under control and not aggravated for three years. 

Now his muscles are stiff and both of his hands are partially paralysed. Complete paralysis of the lower limbs. Aching musculus pirformis of the left buttock, and especially the pains aggravate in the evening. His lower limbs twitch sometimes. No obvious atrophy of the muscles. The skin does not become obviously stiff and thin. Stiffness of the knee joints. Normal patellar jer. Edema of the lower limbs. He is aversion to coldness. Heaviness and stiffness of the whole body. He is easy to be tired. His appetite and sleep are OK.  The bowel movement is once every five days. The urine is yellowish and night urination are 5-6 times. He will be short of breath when talking longer than ten minutes. Dry mouth but no desire to drink.  

Dark reddish tongue body with thin tongue coating. Tooth marks on the edge of the tongue. His pulse is deep and fine and powerful.  

He was healthy in the past and no disease history of hepatitis and tuberculosis or other infectious diseases. No external injury. He has no experience of blood transfusion or medicine allergy. He had undergone an appendix surgery three years ago. There is no such disease case in his family and his son as well as daughter are all healthy. His living condition is good and he has no smoking or drinking addiction. Mr. Farshad is a experienced captain and cheerful in disposition.  

Physical check-up: 

Normal development of his body. The state of mind is clear, passive body posture, chronic sickly complexion. The skin does not have yellow dyes. Poor elasticity of his skin. Slight loss of hair. No bleeding and no tetter. No swelling of the superficial lymph node and no swollen tonsil. The five sense organs and head are normal. The thyroid gland is not swollen. No throat hyperemia. The neck is soft, the trachea is placed in the middle.  

Chest silhouette is normal. His lung works well in breathing and no susurrus. The heart rate is 88 every minute with normal rhythm. His abdomen is soft and ridgy. There are no pressure pains, no rebound tenderness, and no appearance of varicosity on the abdominal wall. The bowel sound are twice per minute. No lump of his abdomen.  

No spine malformation. No pressure pains and no obvious atrophy of the muscles. Stiffness of the muscles and edema of the lower limbs. The thumb cannot extend. The musculus biceps brachii, the musculus triceps brachii, the knee tendon, the heel tendon reflection are normal. 

Diagnosis:

         TCM : Bloodarthralgia (Kidney qi deficiency and insufficiency of kidney yang ) 

         Western Medicine: MS (multiple sclerosis) 

February 22, 2006 

His lower limbs are completely paralysed for 8 years. Aching musculus pirformis of the left buttock, and especially the pains aggravate in the evening. Stiffness of the knee joints and edema of the lower limbs. He is aversion to coldness. Heaviness of the whole body. Easy to be tired. The appetite and the sleep are normal. The bowel movement is once every five days. He would be short of breath if he speaks more than ten minutes. Dry mouth but no desire for water. Dark reddish tongue with thin tongue coating. Tooth marks on the edge of the tongue. His pulse is fine and powerful. 

Astragalus root 10g,     tangkuei 10g,    codonopsis root10g,  Salvia root10g,  etc.

                                                                                                                               Dr. Yangqiuwen 

Prepared aconite main tuber30g,  mugwort leaf20g,  carthamus flower10g,    cinnamom twig10g,  etc.

                                                                                                                               Dr. Yangqiuwen 

February 23, 2006 

The flexibility and strength of his hands are better than before. The swollen feet have relieved. There is no spasm when he gets up in the morning. The examination result shows the function of his kidney and liver are normal. His blood pressure is a bit higher and it is 15g2/112 mmHg. Slight reddish tongue body with thin tongue coating. Fine and powerful pulse. 

 Tangkuei 10g,  earthworm 10g,   salvia root 15g,   silkworm 15g, etc.

                                                                                                                                 Dr. Yangqiuwen

February 25, 2006

The knee joints are painful when he bends the legs, but the spasm has disappeared. His fingers are more agile than before. The edema of lower limbs have further reduced. He has no headache and dizziness. Appetite is normal. Slightly reddish tongue with thin and whitish tongue coating. His pulse is fine and powerful. The bowel movement and urination are normal. The blood pressure is 140/10g6mmHg. 

Silkworm15g,   crataegus fruit15g,  salvia root15g,  earthworm10g,  etc.

The edema of his lower limbs has obviously improved, and has less difficulty in moving. His hands have continued to be improved. Sleep and appetite are normal. The blood pressure is 140/94mmHG. 

February 28, 2006

The edema of his lower limbs has obviously improved. It was very difficult for him to comb his hair with his hands, but today he could do it well. He can lift his hands higher. Reddish tongue with thin tongue coating. Fine and powerful pulse. The blood pressure is 142/92mmHg. 

March 2, 2006 

The condition is the basically the same as several days before. The blood pressure is 140/94mmHg. No bowel movement. The urination is normal. Reddish tongue with thin and whitish tongue coating. Deep and fine and powerful pulse. 

Tangkuei 20g,  earthworm 10g,   silkworm 10g,  millettia root and stem 15g,  etc.

                                                                                                                                  Dr. Yangqiuwen

March 4, 2006 

There were no knee joints pains last night. He can lift his hands over his head. He could not take the bread by his right hand when he was having bread. But he can do it now. In the past, if he stood on his wheelchair he has to use a rope to tight himself. Now, he dose not need it. The edema of his lower limbs has obviously reduced, and we can see his ankle joint tip now. 

March 9, 2006 

The strength of his hands has increased. There is still edema of his lower limbs. Slightly reddish tongue with thin and whitish tongue coating. The pulse is fine and stringy-like. The blood pressure is 128/96mmHg