Record of Hospitalization 

Name: Miss H         Sex: female

Age: 42                     Profession: Math teacher

Nationality: Saudi Arabia

Date of hospitalization: July 1, 2006 

Marital Status: Married

Major complaints:

The patient complained that her lower limbs were lack of strength, and not able to walk for two years since the vertebra operation.

History of present illness:

On January 2004 she felt stiff sense of her lower limbs. Miss H had an examination at the local hospital and showed that nervus vascularis conglutination. Therefore on February she underwent the operation on the seventh to twelfth dorsal vertebral. After the operation, she lost sense of the back part of her right leg. While the sense still exists below the knees. She had walking difficulty of the lower limbs after the operation and she used the wheelchair till now. Her condition improved slightly by the acupuncture treatment in her country. In order to the further treatment, she was admitted to our red cross hospital only July 1, 2006.  

No aversion to the coldness. No fever sense. No headache and dizziness. Occasional urinary incontinence. The bowel movement is once a day. The pulse is deep and fine and moderate. Whitish and thin tongue coating.  

She has no infectious disease history of tuberculosis, hepatitis and typhoid. No history of blood transfusion and no allergy to any medicine.

Physical Examination:

Normal growth of her body and over nutrition. Clear consciousness. No yellow stain of the skin sclera. No edema of the superficial lymph nodes. Normal growth of his head and five sense organs. Sensitive to the light reflection. Normal hearing ability. No edema of the tonsil and thyroid gland.  Thoracic cage is symmetrical. Normal vocal fremitus. Clear percussion sound. The heart rate are 78 times per minute. Normal rhythm of the heart rate. Normal intestinal gurgling sound. No malformation of spinal column and limbs. No feeling sense from the part of left lower limb. The right limb can move but It couldn’t lift.  

Diagnosis of TCM: Paralysis

Diagnosis of western medicine: paraplegia

July 3, 2006 

She slept well last night. No discomfort. The patient could not urinate when she feels urination fullness. So she urinates through catheter everyday. She also couldn’t have the bowel movement herself.  

July 4, 2006 

Since it is inconvenient for her to go to the bathroom, she only has twice urination yesterday. We suggest she should have urination four to five times each day, otherwise there is a possibility to cause urinary tract infection and nephritis. The pulse is deep and fine. Whitish and thin tongue coating.  

cooked rehmannia root  15g，ligusticum root  10g，astragalus root 20g，salvia root 15 g， etc. 

July 5, 2006

Good sleep and appetite. She only has three times of urination. Obvious pressing pains of the left kidney area. We advice again that she must have urination above four times each day.     

July 8, 2006

Good spirit. Relieve of the pressings pains of the left kidney area. She can feel the sense of the left lower limb. There is also slight feeling sense below the knees. Deep and fine pulse. Whitish and thin tongue coating.  

July 13, 2006

The feeling sense of her left lower limb can be felt even obvious. Her right leg also gained the feelings completely. Good appetite and sleep. The pulse is deep and fine. Whitish and thin tongue coating.  

eucommia bark 10g，lycium berry 15g，cuscuta seed  12g，salvia root 15g， etc. 

July 18, 2006

Painful and warm sense of the left knee move to the anklebone. She can feel sense on the back and feet. As to the progress, we can see her condition improving step by step. She keeps on with the herbal tea to consolidate the treatment result.