Brief Summary: On July 19, 2009, Gulrana, from Pakistan, who has suffered from stroke, was hospitalized in our hospital. She has achieved much improvement after 28 days TCM treatment here. Her blood pressure was stable. She could raise her arms to the level of the head. Her right elbow could stretch or bend actively. The spasms in the right hand have improved obviously. Her walking was more powerful in the right lower limb. She could hold on her whole body by standing on the tiptoes without help. The foot drop in the right foot has improved a lot. Her spirit and sleep were good. She has good appetite. The urination and bowel movement were normal.

 

Record of Hospitalization

Name: Gulrana                                                                                                    Birthplace: Pakistan

Sex: Female                                                                                                         Profession: Housewife

Age: 35                                                                                                                Date of Admission: July 19, 2009

Nationality: Muslim                                                                                              Date of Record: July 19, 2009

Marital Status: Married                                                                                        Onset Season: Summer Solstice

Complainer: The patient's husband. The case was recorded by TCM group.

 

First Medical Record

Date: July 19, 2009                                            Time: 20: 00 a. m.

Gulrana, a 35-year-old female, has suffered from dysfunction of the right limb for 3 years. The conditions became more serious with speech disfluency during the recent half a year. She was hospitalized in our hospital at 20: 00 p. m. on July 18, 2009.

Essentials for Diagnosis:

1. The patient has suffered from dysfunction of the right limb for 3 years. The conditions became more serious with speech disfluency during the recent half a year.

2. On June 28, 2006, the patient went to urinate at about 12 p.m., suddenly she felt numb all over the whole body and then fallen down. Her family members carried her to the bed immediately. At that time, she said that her right part of the body were weak and numb. Later the right part of the body could not move freely. Her speech was not fluent. She has been sent to the local hospital (name unknown) for symptomatic treatment. She has been hospitalized for half a year. The condition became a little better. So she came back to her home. At home, she took Indian herbal treatment for 2 months. The improvement was not obvious. The condition became worse gradually. Her speech was not fluent. She came to our hospital for good improvement on July 18, 2009.

3. T 36.2≧, P 80 times/minute, R 20 times/minute, BP 140/90mmHg.

4. She grew normally with common nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. She was cooperative with clear mind.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The myodynamia of the upper and lower parts on the right body was Grade  = 1 \* ROMAN I. The tension of the muscle was too high. The tendon was hyperreflexia, with Babinski's disease (positive). The touch and pain feelings of the right side trunk and body were diminished. Her tongue was red. Her tongue coating was thin. Her pulse was thready and weak.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient has suffered from dysfunction of the right limb for 3 years. The conditions became more serious with speech disfluency during the recent half a year. There were major symptoms such as sudden stroke, feeling barriers. They were the major symptoms of the acute cerebral vascular disease. The touch and pain feelings of the right side trunk and body were diminished. Her tongue was red. Her tongue coating was thin. Her pulse was thready and weak. According to the symptoms of the tongue and pulse, the patient was characterized by the weakness of the limbs and the difficulties in walking and speaking, so she was diagnosed with stroke.

Western Medicine: The patient has suffered from dysfunction of the right limb for 3 years. The conditions became more serious with speech disfluency during the recent half a year. The myodynamia of the upper and lower parts on the right body was Grade  = 1 \* ROMAN I. The tension of the muscles was too high. The tendon were hyperreflexia, with Babinski's disease (positive). She was diagnosed with cerebral hemorrhage sequelae in the local hospital.

Diagnostic Differentiation:

TCM: The patient's stroke should be differentiated from aphasia. If one suffers from stroke, there are symptoms of sudden onset and faint. There are facial distortion, hemiplegia and aphasia to the patient. Or there are only facial distortion and hemiplegia, without faint and falling down. But the epilepsy is a recurrent disease. There are sounds like pig and sheep from the mouth. It could find foams at the patient's mouth. There are spasms on the four limbs. However the symptoms just last a short period of time. Usually, the patient could wake up by himself. After the waking up, the patient has no sequelas of facial distortion or hemiplegia. So they are not difficult to be distinguished.

Western Medicine: The patient's stroke should be differentiated from intracranial tumor stroke. Tumor stroke has a history of intracranial tumor disease, with a slowly increasing intracranial pressure. The patient has barrier with his activity and feelings. There will be a sudden barrier of the consciousness sometimes. So they are not difficult to be distinguished.

First Diagnosis:

TCM diagnosis: Stroke

Symptom identification: qi vacuity and blood stasis, liver wind obstruction of the network channels.

Western medicine diagnosis: sequela of stroke, primary hypertension.

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Under the care of a companion.

4. Common diet.

5. TCM treatment strategy: boost qi, quicken the blood circulation, calm down wind, free the network channels.

6. Herbal tea: one dosage a day and drink twice.

7. Acupuncture and massage: once a day.

8. Have more medical examinations if necessary.

 

Date: July. 21, 2009                                            Time: 10: 00 a. m.

The patient has suffered from dysfunction of the right limb for 3 years. The conditions became more serious with speech disfluency during the recent half a year. The right side of the body was palsy. She could not move her right hand. There were spasms in the right hand and wrist. There was muscular atrophy in the right lower leg. The right foot had foot drop. The right foot ankle was stiff. She felt tired and lack of energy. She had poor appetite. Her speech was not fluent. Her tongue was red. Her tongue coating was thin. Her pulse was thready and weak. The condition is due to qi vacuity and blood stasis, liver wind obstruction of the network channels. The treatment strategy is to boost qi and quicken the blood circulation, extinguish the wind and free the network channels.

 

Date: July. 26, 2009                                          Time: 10: 00 a. m.

The spirit condition of the patient has improved a lot. She could eat more food. The sleeping was also good. The function of the right side body has no obvious improvement. There were spasms in the wrist of the right hand. She had pains in the right lower part of the body. Her tongue was of dark color. Her tongue coating was thin. Her pulse was thready and weak. Continue to take the same prescription.

 

Date: Aug. 1, 2009                             Time: 10: 00 a. m.

Her general condition was good. Her diet and sleeping were good. The condition of the urination and bowel movement were normal. The function of the right side of the body has no obvious improvement. But she said the lower limbs were more powerful. Her tongue was of dark color. Her tongue coating was thin. Her pulse was thready and weak. The former prescription was changed a little. 5 dosages in total.

 

Date: Aug. 6, 2009                             Time: 10: 00 a. m.

Her general condition was good. The right lower limbs got increasing power. The right arm could raise to the level of the head. The spasms in the right hand had got some improvement. In the recent days, there was fluctuation with her blood pressure. The blood pressure was 100/120mmHg to 170/200mmHg. 5 dosages in total.

 

Date: Aug. 11, 2009                            Time: 10: 00 a. m.

After the treatment strategy of enriching and supplementing the liver and kidneys, extinguishing the wind and transforming the phlegm, freeing the network channels, the blood pressure figure was stable between 70/90mmHg to 120/150mmHg. She could raise her arms to the level of the head. Her right elbow could stretch or bend actively. The spasms in the right hand have improved obviously. The right lower limbs had more power. The foot drop has got obvious improvement. She could stand in her right foot toes. Her spirit and diet were normal as before. The sleep was good. The condition of the urination and bowel movement was normal. Her tongue was red. Her tongue body was thin. Her pulse was slippery. 6 dosages in total.

 

 Date: Aug. 16, 2009                            Time: 10: 00 a. m.

After the 30 days comprehensive treatment including herbal tea, acupuncture and massage here, the patient have got obvious improvement. The blood pressure was stable. She could raise her arms to the level of the head. Her right elbow could stretch or bend actively. The spasms in the right hand have decreased obviously. Her walking was more powerful in the right lower limb. She could hold on her whole body by standing on the tiptoes without help. The foot drop in the right foot has improved a lot. Her spirit and sleep were good. She has good appetite. The urination and bowel movement were normal. The patient decided to leave the hospital with 120 dosages of herbal tea back home for continuous treatment.