Name:
Ms. M. Lutz Borromeo Sex: Female
Age: 68
Marital Status: Married
Nationality: Switzerland
Date of Admission: May
26, 2017
Companion: Her
husband
Date: May
28, 2017 Time: 09:00
a.m.
When she
came to our hospital, she complained that she had numbness over
her right finger, muscle atrophy over her four limbs, weakness
and muscle jumping. She took some western medicines for these
symptoms, and recent one month, her condition was getting worse,
muscle atrophy over her whole body was severe. And she also had
difficulty in swallowing and speaking. And there was throat
discomfort. Sometimes she had chest distress. There was edema
over her right lower limb. Her sleeping was not good and she was
impatient. Her urination was normal, the bowel movement was one
to two times a day, loose stool.
Physical
Examination:
T:
36.3<C R: 20 times/minute P: 80 times/minute BP:
120/70mmHg
The
tongue body was slightly red with thin and white coating. The
pulse was slow.
The
patient grew normally with normal body shape. She was alert and
cooperative. She had chronic sick facial complexion.There was no
sign of yellow sclera or yellowish skin and also no enlargement
on the superficial lymph node of her whole body. Facial features
were normal without masses, pressing pains.
The pupils were round and approximately equal in size. The
papillary reaction to light was sensitive. There was no sign of
deformity over her both ears without secreta. There was no
pressing pains and her hearing was normal.
There
was no congestion in her throat and no enlargement over her
thyroid. And the jugular vein was of no engorgement. The
appearance of her trachea was good and in the center. Her chest
was symmetrical. Sound of breathing in the lungs was clear,
without any rhonchi. Rhythm of her heart was 80 times per
minute. Heart rate was regular with no murmurs. Her
abdomen was soft with slight pressing pains, while no rebound
tenderness. There was no sign of deformity over her spine, yet
there were weakness and muscle atrophy over her four limbs.
The meningeal irritation sign was negative.
There were no pathological reflections, but the physiological
reflections existed.
Completed the related examination,
three routine inspection, the function of the kidneys and the
liver, blood fat, blood sugar, anti-O, RF and IMX..
Dr.
Ming, doctor-in-charge, after researching her case, he made the
corresponding treatment strategy according to her condition.