Cerebral thrombosis - Wind stroke (attacking meridian) with blood stasis

[Michael]

SECTION 1: GENERAL INFORMATION
Sex: Female
DOB: 1938
Occupation: Factory worker
M.S.: married

SECTION 2: DATA COLLECTED FROM FOUR DIAGNOSTIC TECHNIQUES
2.1 INQUIRIES:
2.1.1 Chief Complaint: Stiffness of right hand and fingers for 1 month
2.1.2 Present case history: The patient had stiffness of right hand and fingers when moving for 1 month. On 10th of June, the patient woke up 3am in the morning and found numbness of right-hand fingers, and the numbness stayed until the next evening. Later the numbness of the finger aggravated to the severe ness that he could not hold a cigarette. There were no dizziness, no tinnitus, no abnormal tastes or smells in the mouth, no thirst, no dryness of the mouth, and no abnormal sweating. The patient slept well, bowel and urination were all normal.
2.1.3 Previous history: Before the onset of the symptom, the patient had lots of alcohol drinking. Hospitalized before sue to cerebral thrombosis for 17 days.
2.1.4 Personal history: smoker
2.1.5 Family history: The patient’s both parents had stroke histories, no allergic.

2.2 INSPECTION/OBSERVATION:
2.2.1 Spirit: Consciousness: spirit – normal
2.2.2 Complexion: Skin and mucus – no jaundice, no bleeding. Sclera – Normal, no jaundice
2.2.3 Appearance: Facial crease normal / Normal development / Walk normal, cooperate with doctor / Tongue in the middle not deviated / No oedema on both legs.
2.2.4: Body stature: Muscle strength – normal / Muscular tension – stiff on right fingers and slight stiffness on the right leg / Tendon reflex – normal / Skin sensation – normal / All neural responses were normal
2.2.5: Tongue: Slight red body, thin coating, a crack in the middle.
2.2.6: Other parts of the body: Pupil – symmetric, reaction normal / Eye balls moves freely without tumbling / Throat –reflex normal / Neck – soft / Trachea – in the middle / Thyroid – normal / Thorax – symmetric.
2.2.7 Excretion and Secretion: Bowel and urination were normal

2.3 AUSCULTATION & OLFACTION
2.3.1 Auscultation:
Respiration sound – normal, no rale sound, No pathogenic murmur sound.
2.3.2 Olfaction: N/A

2.4 Palpitation:
2.4.1 Pulse: Thready and string-taut pulse
2.4.2 Palpating different parts of the body: N/A

[Michael]

SECTION 3: WESTERN MEDICAL RECORDS
3.1 Physical examination: (Positive signs):
Minor stiffness on the right leg.
3.2 Laboratory tests results
Lab test: CT shown cerebral thrombosis.

SECTION 4: DIAGNOSIS SUMMARY:
4.1 Chinese Medicine Diagnosis
Wind stroke (attacking meridian) with blood stasis.
4.2 Western Medicine Diagnosis
Cerebral thrombosis

[Michael]

SECTION 5: DIFFERENTIATION AND ANALYSIS
5.1 List all the evidence of the differential diagnosis:
Blood stasis – cerebral thrombosis.
Internal wind – numbness at the extremities.
Liver wind, Liver yang flaring up – excessive alcohol caused damp-heat at the liver caused liver Qi stagnation and turn into liver wind rising.
5.2 Analysis of the Aetiology and pathogenesis
Liver wind due to excessive alcohol drinking caused wind-stroke in the meridian resulting stiffness at the extremities. Blood stasis caused the internal wind and numbness sensation at the extremities.
5.3 Principles of treatment:
Invigorate blood, expel internal wind.
Activates meridians and collaterals.
5.4 Prescriptions and Administration
LI5, SI3,4; TE3 and 6 on the right hand plus scalp acupuncture at the motor-area on the left side of the scalp. Needle retention for 1/2 hour, one course treatment for 10 times.

5.5 Measures of prevention and health care.
Regular diet, no raw cold foods; regular and relaxed life style; no over working and no catching cold.