Brief Summary: Miss
H,
from Saudi Arabia, suffered from weakness of the
lower limbs and disability of walking after the vertebra
operation. She has got obvious improvement after
one-month herbal treatment here.
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.
