Patients Name: Mr. M. B. Age: 48 years old
Date of visit: 30-05-2019
Chief complaint: suffer stroke 19 months.
History of present illness: suffered Stroke 19 months ago, resulting in limited limb movements on the left side, The corner of the mouth is skewed to the right, loss of speech function, Head tremor, tremor of the left arm, The left lower limb cannot walk. Hospitalized for seven months. Anxiety and depression..
Physical examination: upper left limb, muscle tension increased, muscle strength normal, shallow feeling decreased. The mouth angle is skewed to the right side, the muscles of the lingual muscles strength are bilaterally symmetrical. The drinking water occasionally coughs, the head and hands are coarse tremor, the head is most prominent, and the frequency is fast. The sound is weak, Dysphonic disorder. Both Stool and urine are normal. Fine pulse. The tongue is reddish and the fur is white.
Mechanism of disease: liver yang transforming into fire；liver wind。
Therapy：乙庚化金（行间XING JIAN，二间ER JIAN），丙辛化水 腕骨(WAN GU)，孔最(KONG ZUI）加左侧足三里(ZU SAN LI)，足陷谷(ZU XIAN GU)。 治疗后，手部震颤基本消失，头部震颤频率以及幅度均有所改善，自觉左侧面颊部肌肉较前有力。
Review. The voice is stronger than before, and the words are clearer than before. The frequency of coarse tremor in the head was significantly weakened, and there was still thick tremor in the left arm, but mainly Muscle tone enhancement.. The pulse on the left wrist is very weak
Review: Occasionally, he can say a half sentence, the voice is loud, and the words are incoherent. The left upper limb is characterized by increased muscle tone. The head is still coarse tremor, but the frequency is significantly reduced.
刺太溪(TAI XI)，太冲(TAI CHONG)；太冲以应手阳明，手少阳，收敛阳气，未果，仍然刺合谷(HE GU)，中渚(ZHONG ZHU)，以阖阳气；加通里(TONG LI)以应心，改善语言。丙辛化水以治本。
Review. The fourth acupuncture treatment today. Last time I said that the treatment of Increased muscle tone in the left upper limb with the KAI HE SHU method，now look is satisfactory, and Excessive muscle tone is obviously relieved. According to his family’s representative, the smell of the left nostril improved, the cold and hot feelings on both sides of the body improved, and the eyesight improved. Dysphagia has improved (drinking water and cough, it should belong to pseudobulbar paralysis), but the left lower limb muscle strength is poor, and the step is erratic. Therefore, today, the left lower extremity is applied to KAI HE SHU method to see if it can improve the lower limb muscle strength.
右侧合谷(HE GU)加中渚(ZHONG ZHU)以解痉；加左侧通里(TONG LI)以应心；加左侧丘墟(QIOU XU)，足通谷(ZU TONG GU)，以改善左下肢肌力。