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.