Record
of Hospitalization
Name: Xie Jieni Nationality: Malaysia
Sex: Female Age: 53
Marital Status: Married The Date of Admission: May 12, 2006
Chief complaints: Her lower limbs could not walk for
three and half a years, and she can not control her urination for one and a
half years.
History of Present Illness:
In January of 2003, her lower limbs became weak, and numb
without any reasons. Then she could not walk. She underwent treatment in
several hospitals in Singapore and Malaysia. Doctors diagnosed the illness
as ¡°multiple spinal cord sclerosis¡±. During these treatments there was a
little relief, but it relapsed. Since January of 2005, she could not control
her urination and she has to use a catheter for urination.
By the internet she found our hospital and came here for
TCM treatment. At present, she has no headache or fever. Her sense of
wellbeing is good, and her appetite is normal. Her bowel movement is once a
day or every other day. She has bedsores because she was always in bed.
History of past illness: She had constipation, and
bedsores before, but she did not take any medicines. She has no history of
operation, trauma or allergy to medicine. She has no experience of blood
fusion.
Personal history:
She was born in Malaysia, and the living condition were
good. Malaysia has a humid climate and hot weather. She likes spicy foods.
She has no addiction to alcohol or tobacco.
Physical examination:
Ne Nervous system is
ok. She speaks clearly. Breath is normal. There was no abnormal sign found
of her five sense organs. The rhythm of the heart is 74/min. Her upper limbs
can move but are weak, especially her left hand. Her lower limbs can not
move. There is no swelling or malformation of her knees and ankles. The
patellar relex is normal. There is no feeling of cold or warm below her
navel.
Diagnosis:
Chinese medicine: 1.Wilting
pattern (spleen and kidney Yang deficiency)
2. Decubitus
Western medicine: 1.
Multiple spinal cord sclerosis
2. Bedsore
with infection
May 12, 2006
Today Dr Ming and I checked
the patient. There is a bedsore on her back. Ti is as
big as 5¡Á3.5cm. and 7cm
deep. The bedsore is pale. Her sleep is good and she
dose not have any other
uncomfortable feeling.
May 13, 2006
She slept well last
night and her spirit is well. She had a bowel movement is the
morning with a
little urine. Her pulse is deep and thin, the tongue fur is whitish and
thin. She dose not
have fever.
May 14, 2006
The patient said she had a fever last night. But no
headache or blocked nose. The body temperature was 37.5¡æ at that time. The
pulse is deep and fine, and the tongue fur is whitish and thin.
May 15, 2006
Last night, she felt a little aversion to cold, but she
did not have headache or lumbago and her body temperature was 37.6¡æ.
According to the result of the blood and urine test, she used a catheter for
a long time. We suppose she has urethritis. Her pulse is a little rapid, and
her tongue fur is thin and whitish.
May 16, 2006
The X-Ray of pelvis shows there is damage to the coccyx,
especially the caudal vertebra. There is no obvious sign of dead bone.
May 19, 2006
After several days of treatment, she can lift her hands
higher and she feels stronger. Her lower limbs have no obvious improvement.
Her pulse is deep and thin and her tongue fur is thin. Now our treatment
principal is strengthening the spleen and replenishing qi; nourishing the
liver and kidney.
May 22, 2006
This morning, we could see the patient¡¯s feet are in a
natural position. Her hands are obviously stronger than before. She can hold
the fork to eat with her left hand.
May 25, 2006
Her energy is good today and she is confident of the
treatment. We decide to stop using antibiotics. Her pulse is deep and fine,
and her tongue fur is whitish and thin.
May 29, 2006
We stopped the antibiotics for 5 days. She did not have a
fever or any uncomfortable feeling. Her abdomen has feeling now. Her left
leg has feeling up to her knee; her right leg has feeling up to her thigh,
and her hip also has feeling now.
June 1, 2006
She did not have a fever today. Her sleep was well. The
feeling in her lower limbs is recovering step by step. Her whole condition
has improved remarkably. The treatment principal is to strengthen the
spleen, to replenish qi; and to nourish the liver and kidney.
June 5, 2006
She is getting homesick these days, and she could not
sleep well or eat well. Her pulse is deep and fine. Her tongue fur is thin
and whitish.
June 8, 2006
Her sleep became better. The feeling in her lower limbs
has nearly recovered.
June 12, 2006
The feeling in her lower limbs has recovered completely.
She can twist her waist and hip by herself. Because she misses her family so
much, she has decided to discharge on 17th June.
The patient discharged on 17th June.
She can feel that her upper limbs are stronger than before. She can speak
more clearly. She has more energy. She had no feeling below her navel before
she came to our hospital and after the treatment the feeling has recovered.
Also, she can twist her waist now.
¡¡
More
other successful treatment cases for MS:
Case-1
Case-2 Case-3
Case-4 Case-5
Case-6 Case-7
