Name: Xu Yansheng                                                           Sex: Male

Age: 42                                                                               Marital Status: Married

Nationality: China                                                               Date of Admission: Jan. 08, 2015

Companion: Alone 

                                          First Medical Record 

Date: Jan. 08, 2015                                Time: 11:00 a.m. 

This 42-year-old man has been suffering from stroke. The right side of his body was slightly paralysed for one month. He could not move flexibly. His condition became worse for 4 days. He was hospitalized in our hospital as a patient with sequel of cerebral infarction for TCM treatment at 11:00 a.m. on Jan. 08, 2015. 

Essential for Diagnosis: 

1. The right side of the patient’s body was slightly paralysed for one month, and the condition was getting worse. The patient took the following western medicine, Aspirin Enteric-coated Tablets 100mg×1 tablet (once a day); Atorvastatin Calcium Tablets 20mg×1 tablet (once a day); Butylphthalide Soft Capsules 0.1g×1 tablet (three times a day). There were no food and medicine for him to get allergy response.

2. When the patient came to our hospital, there was limitation of movement over the right side of his body, accompanied with claudication. And his right arm could not bend flexibly. His fingers were difficult to move. His fingers could not hold something. And he could not lift his arm. The right side of his body was of lack of power. He had numbness over his right face. Sometimes he had headache. He felt hot over his four limbs. His vision was not clear. He felt dry and bitter mouth. He preferred cold drink. His speech was not fluent. Sometimes he had saliva out. His sleep and appetite were good. And his urination and bowel movement were normal. Sometimes he was of sweated.

3. T: 36.5°C   R: 20 times/minute    P: 82 times/minute   BP: 140/90mmHg 

4. The patient had normal growth, physique and spiritual status, yet his speech was not fluent. There was limitation of movement over the right side of his body. He cooperated with doctors when the physical examinations were made. There was no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. His neck was soft with no resistance. His trachea and chest were symmetrical. There was no congestion in his throat. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 82 times per minute. Heart rate was regular with no murmurs. His abdomen was soft with no pressing pains and rebound tenderness. There were no signs of deformity over his spine and four limbs. There was Hofmann sign. His biceps reflex was weak. The reflex over his right knee disappeared. The meningeal irritation was negative. The tongue body was reddish with white and thick coating. The pulse was taut and rapid.

5. Imaging examination at the No. 1 People’s Hospital in Huaihua, the result of CT showed cerebral infarction and sinusitis.

Diagnostic Differentiation: 

TCM: Stroke (the recovery period)

Western Medicine diagnosis: Sequel of cerebral infarction and hypertension

Treatment strategy and nursing: 

1. Routine care of traditional Chinese internal medicine. 

2. Grade Ⅱ care, companion, low fat and salt diet.  

3. Complete the related examination, three routine inspection, the function of the kidneys and liver. 

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

5. Acupuncture and massage: once a day 

Date: Jan. 09, 2015                                      Time: 9:00 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient this morning. This 42-year-old man has been suffering from stroke. The right side of his body was slightly paralysed for one month. He could not move flexibly. His condition became worse for 4 days. He was hospitalized in our hospital as a patient with sequel of cerebral infarction for TCM treatment at 11:00 a.m. on Jan. 08, 2015. When the patient came to our hospital, there was limitation of movement over the right side of his body, accompanied with claudication. And his right arm could not bend flexibly. His fingers were difficult to move. His fingers could not hold something. And he could not lift his arm. The right side of his body was of lack of power. He had numbness over his right face. Sometimes he had headache. He felt hot over his four limbs. His vision was not clear. He felt dry and bitter mouth. He preferred cold drink. His speech was not fluent. Sometimes he had saliva out. His sleep and appetite were good. And his urination and bowel movement were normal. Sometimes he was sweated. The tongue body was reddish with white and thick coating. The pulse was taut and slightly slippery. Dr. Ming made the treatment strategy and plan according his condition.

Date: Jan. 10, 2015                                      Time: 9:00 a.m.

The patient said the headache relieved. His appetite and sleep were good. There was no night sweating. His bowel movement was good. The pulse was taut and slippery. The tongue body was reddish with white and thin coating. Continue to take the same formula. This morning the doctor made a test for power of gripping, his left hand was 15 kilos, his right hand was 0.

Date: Jan. 11, 2015                                      Time: 9:00 a.m.

The patient said the headache disappeared. His appetite and sleep were normal. His urination and bowel movement were good. The tongue body was reddish with white and thin coating. His blood pressure was stable. To test the blood pressure twice a day.  

Date: Jan. 14, 2015                                      Time: 9:00 a.m.

The patient said the function of lifting over his right arm was improved. The saliva reduced. But the right side of his body was still of lack of power.

Date: Jan. 17, 2015                                      Time: 9:00 a.m.

The patient said the power over his right leg increased. There is no thirsty and headache. There was no numbness over the right side of his body. Yet the limitation of movement over his right arm was still the same. His appetite was good. His sleep was not good because he worried too much about his condition. The tongue body was reddish with white and thin coating. The pulse was taut.

Date: Jan. 20, 2015                                      Time: 9:00 a.m.

The patient said his vision was not clear. Sometimes he had dizziness and he felt tired. He felt the power of the right side of his lower limb had been increased greatly with no numbness and pains. His appetite was good. His sleep was good but he was easy to wake up. The tongue body was reddish with yellow and thick coating. This morning the doctor adjusted the formula.

Date: Jan. 23, 2015                                      Time: 9:00 a.m.

The patient said his dizziness and blurred vision were better. The other symptoms were the same. To continue the formula.

Date: Jan. 24, 2015                                      Time: 10:30 a.m.

The patient decided to leave the hospital tomorrow. His current condition: The power of the right side of his lower limb increased obviously. His walking improved greatly. It was still difficult to bend and lift his arm. There were no numbness over his face and no headache and dizziness. His vision was still not clear, but it was obviously improved. There was no thirst. And his saliva reduced. His appetite and sleep were good. The tongue body was reddish with yellow and thick coating. The pulse was taut.

Doctor’s advice after leaving hospital: 

1. Avoid wind-cold. 

2. Take care of the diet.