Record Of Hospitalization
Name: Miss D Sex: Female
Age: 35 Marital Status: Married
Nationality: Bulgaria Date of Admission: December 2, 2005.
Record Date: December 2, 2005.
Major complaint: Lumbago and painful legs. Walking difficulty, lower limbs with macules and blood stasis clots and for 7 years.
Disease history: Miss D has uncomfortable feeling in the left leg with numbness and pains, itching skin as well as many macules and stasis clots on her lower limbs since 1999. Over the recent two years, she often has sweating, chest oppression, shortness of breath and difficulty in swallowing as well as frequent urination and cold body. No edema on the lower limbs. When pressing her limbs, they did not become sunken. Her appetite is common and sleep is not good. Her bowel movement is normal. No obvious changes of her weight during these years. She did not feel helpful about the medicine she used in the past few years. Slightly reddish tongue body with greasy tongue coating. Deep tooth-marks on the edge of the tongue. Her pulse is fine and soggy.
The patient’s constitution is common and she has had nephrolith, cholecystitis before. She dose not have history of tuberculosis and hepatitis or other infectious diseases. She has no experiences of blood transfusion or allergy to medicine. No external injury.
Miss D was born in Bulgaria, and her living condition is ordinary. She has no severe trauma and has smoking addiction. She has a 13 years old child. Her family are healthy. Normal menstruation.
Physical check-up: Normal development of her body. Clear consciousness. Her complexion is dull and dry. Elasticity loss and pale skin. Her body temperature is normal. There are many stasis macule on the skin of the lower limbs. Her lymph node is normal. No swellings. No pressure pains and no malformation of the head bone. She has dense and lustrous hair. No loss of eyebrows. No dropsy and no drooping of the eyelids. No jaundice of eyes, no bleeding and no lymph node swelling. No yellowish and infectious sclera. Transparent cornea. Normal size of the pupillae and respond well to the reflection of light.
Her hearing and noses are normal. No nasal obstruction. No secretion from noses. There is no bad smelling in her mouth. Her teeth, lips and tonsil are OK. Thick and greasy tongue coating. We can see the beating artery in the neck. The hypothyroid is normal. There is no malformation, pressure pains of her chest. No varicosity of the chest wall. No swelling in her breasts.
Bicepa brachii tendon, musculus triceps brachii tendon of two sides and two knee tendons, heel tendons are normal.
The patient has uncomfortable feeling in the left-side limbs, and along with numbness, itching skin and pressure pains, as well as many macule and stasis clots on her lower limbs since 1999. Over the recent two years, she sometimes has sweating, chest oppression, shortness of breath and difficulty in swallowing and cold body and poor sleep quality. Slightly reddish tongue body. Greasy tongue coating. No tooth-marks on the edge of the tongue. Her pulse is fine and soggy.
Assistant examination: CT, X Ray, Blood platelet check-up, three Major Regular Exams.
Diagnosis:
Blood Numbness Pattern (wind, cold and damp pattern) (Traditional Chinese Medicine).
MS (multiple sclerosis) (Western Medicine).
Treatment methods include herbal tea, twice a day, massage and acupuncture once a day.
astragalus root 18g salvia root 18g duhuo angelica root 12g buck grass 12g, etc .
Dr. Yang Qiuwen
December 3, 2005.
The patient said that her sleep is much better after two doses of the herbal tea.
astragalus root 30g salvia root 25g tangkuei 30g codonopsis root30g, etc.
Dr. Yang Qiuwen
December 4, 2005.
The pains and stiffness of lower limbs are relieved. Her menstruation has delayed for 5-7 days..
astragalus root 18g salvia root 18g duhuo angelica root 12g buck grass 12g, etc .
Dr. Yang Qiuwen
December 6, 2005.
Lumbago and the cold sense of the limbs have disappeared. The pains of knee joints are much relieved. She can dance now. She stopped to dance for 8 years because of her disease. There is a great improvement of her condition. Greasy tongue coating.
astragalus root 30g salvia root 25g tangkuei 30g codonopsis root 30g, etc.
Dr. Yang Qiuwen
December 8, 2005.
She can walk with more strength than before. Movement of her fingers is much better. No pains at her back, waist, and legs. Less distention of the right foot than before. There are pains of her feet when pressing them. Sleep is good. Thick and greasy tongue coating. Deep and fine pulse.
astragalus root 30g salvia root 25g tangkuei 30g codonopsis root30g, etc.
Dr. Yang Qiuwen
December 10, 2005.
There is very obvious improvement of lumbago. Distending pains of the right foot as well as painful insteps and ankle joints. The right foot is stronger than before. The right knee joint is still a little painful. Obvious improvement of the stiff muscles and pains of back and shoulders.
astragalus root 40g salvia root 25g tangkuei 15g codonopsis root 25g, etc.
Dr. Yang Qiuwen
December 12, 2005.
There are no painful feelings in the morning, but the lower back pains in the afternoon. She has aching pains of her back if she sits for long.
fresh ephedra 4g millettia root and stem 10g ginseng root 10g carthamus flower 10g, etc.
Dr. Yang Qiuwen
December 13, 2005.
The pains all over have much improved. She feels tired if standing for long. Weak waist. We will focus on tonifying the kidneys.
December 16, 2005.
She feels very good today. The pains in her waist and back have disappeared. The numbness of her fingers has disappeared too and with flexible movement. No numbness of her left side now. She feels a little tired after going shopping today.
The left ankle joint still has pressure pain and limited movement. Normal bowel movement and urination. Appetite is good. Slightly reddish tongue with thick and greasy tongue coating. There are tooth-marks on the edge of the tongue. Deep and fine pulse.
We will fortify the spleen and boost the kidney; warm Yang and transform rheum; quicken the blood circulation and transform blood stasis.
astragalus root 50g salvia root 25g tangkuei 30g codonopsis root30g, etc.
Dr. Yang Qiuwen
December 18, 2005.
There is a little lumbago, when she does some washing. She has a little numbness of the left foot. Heavy sense of the right foot. Slight sense of the left foot. Stiff feet when she gets up in the morning. There is stiff muscle of inner side of her legs if she walks. No dry mouth. No sore throat. Bowel movement and urination are normal. Her pulse is deep and fine.
astragalus root 60g carthamus flower 6g tangkuei 15g codonopsis root10g, etc.
Dr. Yang Qiuwen
December 19, 2005.
Numbness of left foot and stiffness of the inner side of her legs have disappeared. Heavy sense of the right foot. Weakness of her left ankle joint. She can raise her right foot naturally on the bed, but there is distention of her back when she raises her left foot. The distention of muscles of her right leg has disappeared, only a little distention of her knee now. She can feel stiff knees if she walks for long. Slightly reddish tongue body with thick and greasy tongue coating. The pulse is deep, fine and soggy.
December 20, 2005.
There is pain at her back. Her left foot is weak when having a walk. She feels tired today. Dark reddish tongue body with greasy and yellowish tongue coating. Her pulse is deep and fine.
Tangkuei 10g ovate atractylodes root 15g astragalus root 60g carthamus flower 10g, etc.
Dr. Yang Qiuwen
December 21, 2005.
Muscular weakness and pains of the left arm. Weakness of waist and the left ankle joint. She can raise her left leg higher, but it still causes distention of back. The right foot is not as heavy as before. She has dark purple tongue and the tongue coating is thick and greasy. She has dry mouth and desire for water.
December 22, 2005.
Lumbago when lying. The numbness of four limbs, stiffness of muscles and burning sense have disappeared. No blood stasis clots and macule. Because of fatigue, she can not do more exercise. Dark reddish tongue body with greasy and yellowish tongue coating. Frequent urination. Dry mouth but no desire for water. Her pulse is deep and fine.
astragalus root 60g salvia root 15g duhuo angelica root 10g tangkuei 15g, etc.
Dr. Yang Qiuwen
December 24, 2005.
No numbness and no pains. No fatigue today. When she goes down-stairs her knee joints feel weak. Poor stability when walking. Cold feet. Heavy sense of the right foot has improved. Dark reddish tongue body with greasy and yellowish tongue coating. Her pulse is soggy and fine.
astragalus root 60g salvia root 15g duhuo angelica root 10g tangkuei 15g, etc.
Dr. Yang Qiuwen
December 26, 2005.
The ankle joints are not so flexible when she goes down stairs. Limited movement of the left toes. Heavy feet have been further relieved. Reddish tongue with thin and yellowish tongue coating. The pulse is deep and fine and powerful.
astragalus root 60g salvia root 15g duhuo angelica root 10g tangkuei 15g, etc.
Dr. Yang Qiuwen
December 27, 2005.
Pains at her back, and it relieved when she rests in bed. There are tense muscles inside in her left foot after walk for long. She still has slight sense of the left foot. The cold sense of left foot has disappeared. Heavy sense on her right upper leg. Dark reddish tongue with thin and yellowish tongue coating. Her pulse is deep and fine.
December 28, 2005.
She walks for 30 minutes today. But she is not tired. She just feels a little distention and pains of ankle joints and muscles of thigh. The movement of ankle joints is limited. No dry mouth. Her bowel movement and urination are normal. Dark reddish tongue with thin and yellowish tongue coating. Her pulse is deep and fine.
astragalus root 60g salvia root 15g duhuo angelica root 10g tangkuei 15g, etc.
Dr. Yang Qiuwen
December 30, 2005.
She feels good today. Her knee joints are not as difficult as before when she goes down-stairs. Weak ankle joints. Cold feet. The pain of her back has disappeared. Veins can be seen on the inside and outside her thigh. She has distention and pains of breasts and waist. Slight pains in the abdomen. No headache. She has dry mouth but without desire for water. Her bowel movement and urination are normal. Reddish tongue with thin and yellowish tongue coating. Her pulse is deep and fine.
January 1, 2006.
Cold sense of the toes. Fatigue. She can raise her feet naturally. A little bit tired of left foot if she walks for long distance. Her appetite is good and sleep is well. Her bowel movement and urination are normal. Slightly reddish tongue with thin and yellowish tongue coating. Her pulse is deep and fine.
astragalus root 60g salvia root 25g duhuo angelica root 6g tangkuei 15g, etc.
Dr. Yang Qiuwen
January 3, 2006.
The cold sense of the toes has disappeared. Her walking ability is much better than before, she even can run slowly and does not feel tired. There is still a little weakness of her ankle joints. Her sleep and food in-take are good. Reddish tongue with thin and yellowish tongue coating. Her pulse is deep and fine. She has deficiency of body fluid.
astragalus root 60g salvia root 25g duhuo angelica roo t6g tangkuei 15g, etc.
Dr. Yang Qiuwen
