Name: Miss Nino                                                               Sex: Female

Age: 31                                                                              Marital Status: Married

Nationality: Georgia                                                          Date of Admission: June 29, 2017

Companion: Her friend

Date: June 30, 2017                                Time: 09:30 a.m.

When she came to our hospital, she complained that 2 years ago she had numbness over her right finger, muscle atrophy over her four limbs, weakness and muscle jumping. She took some western medicines for two years and there was no progress and improvement. Recent one month, her condition was getting worse, muscle atrophy over her four limbs was serious, especially her upper limbs. And she also had difficulty in swallowing and speaking. Sometimes she had dizziness. There was no sweating at night. Her sleeping was not good, her appetite was normal. Her urination was normal, the bowel movement was one to two times a day, loose stool.

Physical Examination:

T: 36.3°C   R: 20 times/minute    P: 80 times/minute   BP: 90/60mmHg 

The tongue body was slightly red with thin and white coating. The pulse was slow.

The patient grew normally with normal body shape. She was alert and cooperative. She had chronic sick facial complexion. There was no sign of yellow sclera or yellowish skin and also no enlargement on the superficial lymph node of her whole body. Facial features were normal without masses, pressing pains. The pupils were round and approximately equal in size. The papillary reaction to light was sensitive. There was no sign of deformity over her both ears without secreta. There was no pressing pains and her hearing was normal. There was no congestion in her throat and no enlargement over her thyroid. And the jugular vein was of no engorgement. The appearance of her trachea was good and in the center. Her chest was symmetrical. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of her heart was 80 times per minute. Heart rate was regular with no murmurs. Her abdomen was soft with slight pressing pains, while no rebound tenderness. There was no sign of deformity over her spine, yet there were weakness and muscle atrophy over her four limbs. The meningeal irritation sign was negative. There were no pathological reflections, but the physiological reflections existed.

Completed the related examination, three routine inspection, the function of the kidneys and the liver, blood fat, blood sugar, anti-O, RF and IMX..  

Dr. Ming, doctor-in-charge, after researching her case, he made the corresponding treatment strategy according to her condition.