Record of Hospitalization

Name: Mr. R                          Sex: Male

Age: 27                                 Marital status: Single

Nationality: Bulgaria              

Date of Hospitalization:  December 1, 2005.

Major complaint: His lower limbs lack of strength for two years, and his left eye has double vision. The problems have become worse in the latest two months. 

Disease history:

He felt that his lower limbs lacked strength without obvious reason, two years ago. Stiffness of the ankle joints. Limited movement of the knee joints. Over the past half an year, he found that he could not see things clearly with the left eye and the double vision appeared. He always felt dizzy and lack of balance while walking. When he went up and down stairs he had to hold the handrail. If he walked for 50 meters, he would feel very fatigue and obvious stiff of his lower limbs. He has taken the treatment in his local hospital for two years but with no effect.  

At present, he has stiffness of the left knee and ankle joints. Night sweating sometimes. Dry throat. Bad spirit and easy to be tired. The patient has insomnia and poor appetite. His bowel movement is once every 7-9 days, and the stool is constipated. His urination is not smooth and there is dribbling after urination. Reddish and dry tongue body with no tongue coating. There are many deep fissures on his tongue. Thready and rapid and feeble pulse. 

He does not have history of tuberculosis and hepatitis or other infectious diseases. He has no experience of blood transfusion or allergy to medicine. No external injury.  

He was born in Bulgaria and his living condition is ordinary. He has never been to the places where have contagious diseases. He likes smoking and drinking coffee. He is a good firefighter and is very optimistic. There is no such disease case in his family.