September 24, 2010, Zahra, from Iran, who has suffered from flaccidity disease and hysteromyoma

On September 24, 2010, Zahra, from Iran, who has suffered from  flaccidity disease and hysteromyoma was hospitalized in our hospital. She has had the problem of speaking and movement of her limbs for 22 years. After nearly two months treatment, she achieved a good result.

                                                                    Record of Hospitalization

Name: Zahra                                                                                            Birthplace: Iran

Sex: Female                                                                                              Profession: Student

Age: 23                                                                                                     Date of Admission: September 24, 2010

Marital Status: Unmarried                                                                        Date of Record: September 24, 2010

Nationality: Iran                                                                                       Onset Season: Autumnal Equinox

Complainer: The patient herself

Major Complaints: She has had the problem of speaking and movement of her limbs for 22 years.

Present Illness: Due to dystocia, the patient's mother had the cerebral hypoxia. When patient grew to 4 years old, her father found that she could not speak fluently and walk steadily. When she walked, it was very easy for her to fall down. Then, her parents took her to hospital. MRI showed that her brain was damaged. The diagnosis was sequelae of cerebral palsy. The patient didn't take any medication just had rest at home. When patient get older and older, her condition became worse and worse. During May to July of this year, the patient got better after taking the herbal tea which we posted to her. Now, the patient has the problem of speaking and movement of her limbs and general weak body. Sometimes, when she raised her upper limbs, her hands will shake. Because of loss of power, she can not hold the pen when she writes things, and her hands will shake. Also, she has the problem of near sighted, dry mouth, but she has good spirit and appetite.

Disease History: In 2007, the patient found that she had fibroid, but she didn't take any medication. She is not allergic to any food or medicine. She has no history of blood transfusion or operation .

Personal History: She was born in Iran and never gone to any foreign country. She lives in dry environment, likes any meat food and fried food.

Marriage History: She was unmarried.

Menstrual History: She had her first menstruation at her 15 years age. She has dysmenorrhea, and the volume of her menstruation is a little bit much than normal and accompany with blood spot.

Family History: No family members got the similar disease before. 

Physical Examination

T: 36.3℃   P: 77bpm   R: 20bpm   BP: 98/60mmHg

She was mid-nourished and normally developed. Her mild was clear. Her skin was moist. Her neck was soft and trachea is in the middle. No superficial lymph-node enlargement. No enlarged thyroid. Sound of breath was bilaterally normal on auscultation. Heart border was normal. Heart beat 77/min. Cardiac rhythm was regular. No pathological murmurs on auscultation. Abdomen was flat and soft without tenderness or rebound tenderness. The liver and spleen were not palpable. No deformity, but, sometimes when she raised her upper limbs, her hands will shake. Because of her weak body, she can not hold a pen when she writes things, and her hands will shake. She can not walk steadily. Also, She has slightly pale tongue body and thick tongue coating and weak pulse.

First  Diagnosis:

Assistant Examination: 1. MRI: Damaged Brain

                                   2. B ultrasonic: Womb Fibroid

 TCM diagnosis: Wei-syndrome (flaccidity syndrome) Zheng-syndrome (fibroid)

Symptom Diagnosis: marrow sea deficiency, deficiency of blood and Qi

Western medicine diagnosis: sequelae of cerebral palsy, fibroid

Diagnosis Basis: TCM: The patient had had the problem of speaking and movement of her limbs for 22 years. TCM believed that congenital dystrophy, the loss of kidney essence and marrow sea can cause these problems. Also, She has slightly pale tongue body and thick tongue coating and weak pulse.  Western medicine: 1. She had the cerebral hypoxia when she was born 2. She can not speak fluently and walk steadily and general weak. 3. Sometimes, when she raised her upper limbs, her hands will shake. Because of loss of power, she can not hold a pen when she writes things, and her hands will shake. 4. MRI: Damaged Brain

Plan of treatment and care

1. On routine care of traditional Chinese internal medicine

2. On grade Two care

3. Under care of a companion

4. Low-fat protein diet

5. Therapeutic Principle: Reinforcing kidneys, strengthening brain; nourishing Qi and blood

6. Herbal tea: One dosage a day and drink twice, each time 180ml

7. Acupuncture and massage: Once a day

8. Have more medical examinations if necessary

Date: September 25, 2010                     Time: 10:00 a.m.

Due to dystocia, the patient's mother had the cerebral hypoxia. When patient grew to 4 years old, her father found that she could not speak fluently and walk steadily. When she walked, it was very easy for her to fall down. Then, her parents took her to hospital. MRI showed that her brain was damaged. The diagnosis was sequelae of cerebral palsy. The patient didn't take any medication just had rest at home. In 2007, the patient found that she had fibroid, but she didn't take any medication. Now, the patient's condition became worse and worse. Her illness is the problem of speaking and movement of the four limbs and fatigued body. Sometimes when she raised her upper limbs, her hands will shake. Because of her weak body, she can not hold a pen when she writes things, and her hands will shake. Also, She has slightly tongue body and thick tongue coating and weak pulse. So, Professor Zhang diagnosed her with Wei-syndrome (flaccidity syndrome) and Mass-syndrome (fibroid).

Date: September 27, 2010                     Time: 10:00 a.m.

The patient has no obvious change of her body. Yesterday, she has clear menstruation.

Date: September 30, 2010                     Time: 10:00 a.m.

The patient gained more power of her body.

Date: October 6, 2010                     Time: 10:00 a.m.

The power of the four limbs was increased. And the situation of her writing and walking got better.

Date: October 11, 2010                     Time: 10:00 a.m.

At October 8, the patient did MRI on her head, but the result showed no obvious problem.

Date: October 16, 2010                     Time: 10:00 a.m.

The movement of her four limbs is much better than before, and the power of her four limbs is increased. She is getting better about her walking. There were no pains on her abdomen and menstruation ended.

Date: October 21, 2010                     Time: 10:00 a.m.

The patient is in a stable situation.

Date: October 26, 2010                     Time: 10:00 a.m.

The patient has good spirit, appetite and sleep.

Date: October 30, 2010                     Time: 10:00 a.m.

The patient has good spirit. The movement of her four limbs is much better than before, and the power of her four limbs is increased. Also, the balance of her walking is improved greatly. The patient has urinary incontinence, and we are waiting for the result of her liver and kidneys and urine test.

Date: November 4, 2010                     Time: 10:00 a.m.

The urine test shows that it is normal. The urinary incontinence is improved during recent days. At the most time, she can control her urination. When she lies down on the bed, she will feel pains on her abdomen.

Date: November 9, 2010                     Time: 10:00 a.m.

The patient gets a big improvement of her urinary incontinence. She can move her figures more freely. Also, her writing is getting better. The balance of her walking is improved. And she coughs up clear phlegm. But, the fluent speaking is still a problem.

Date: November 13, 2010                     Time: 10:00 a.m.

The patient's menstruation is normal and the menstrual period is 7 to 10 days. The urinary incontinence is not a problem for patient anymore. The whole situation of her is getting better.

Date: November 18, 2010                     Time: 10:00 a.m.

The movement of her limbs is improved. No shaking and blurred speaking. She has normal spirit, sleep and appetite. The volume of her menstruation is less and the  menstrual period is 6 to 7 days.

Date: November 23, 2010                     Time: 10:00 a.m.

The whole situation of patient is getting better.

Date: November 26, 2010                     Time: 10:00 a.m.

The problem of her urinary incontinence is recovered completely.

Date: November 30, 2010                     Time: 10:00 a.m.

The movement of her limbs is improved further. She can move her figures more freely. Also, her writing is getting better. The balance of her walking is improved. She has normal spirit, sleep and appetite.

Date: December 4, 2010                     Time: 10:00 a.m.

The patient is in a low mood during recent days. She has no obvious continuous improvement and just in a  stable condition.

Date: December 7, 2010                     Time: 10:00 a.m.

Today, the patient is going to leave.