Brief Summary: On Jan. 08, 2015, Mr. Xu Yansheng, from the village of Jielong near our hospital, who had been suffering from stroke for one month. The right side of his body became paralysed. And his condition is getting worse. He was hospitalized in our hospital. He achieved great improvement after 17 days TCM treatment with the help of herbal tea, acupuncture and massage in our hospital.

Record of Hospitalization 

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.