Marital Status: Married
Date of Admission:
30, 2017 Time: 09:30
came to our hospital, she complained that 2 years ago she had
numbness over her right finger, muscle atrophy over her four
limbs, weakness and muscle jumping. She took some western
medicines for two years and there was no progress and
improvement. Recent one month, her condition was getting worse,
muscle atrophy over her four limbs was serious, especially her
upper limbs. And she also had difficulty in swallowing and
speaking. Sometimes she had dizziness. There was no sweating at
night. Her sleeping was not good, her appetite was normal. Her
urination was normal, the bowel movement was one to two times a
day, loose stool.
36.3＜C R: 20 times/minute P: 80 times/minute BP:
tongue body was slightly red with thin and white coating. The
pulse was slow.
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.
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
Completed the related examination,
three routine inspection, the function of the kidneys and the
liver, blood fat, blood sugar, anti-O, RF and IMX..
Ming, doctor-in-charge, after researching her case, he made the
corresponding treatment strategy according to her condition.