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 5×3.5cm. 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℃ 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℃. 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 17^th June.