Brief Summary: Audra, from Lithuania, has suffered from MS for 5 years. She came to
our Red Cross Hospital on April 28, 2007 for our TCM
treatment. After two month comprehensive treatment, the patient has
achieved about 30% improvement.
¡¡
Record of
Hospitalization
Name:
Audra
Sex: Female
Age:
50
Profession: Surgeon
Nationality:
Lithuania
Marital Status: Married
Onset Season:
Spring
Date of Admission: April 28, 2007
Complainer:
The patient¡¯s herself
Reliability: Reliable
Major Complaint:
The
patient has suffered from
rigidity and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5 years, and her
condition has been aggravated by disability of walking for 2 years.
Present Illness:
In 2002, the patient began to feel
rigidity and weakness
of her double limbs¡¯ muscular without any obvious causes. At that time, the
patient paid no attention to it, and did no treatment about it. Therefore, the
disease was developing progressively. After three months, she began to walk
unsteadily, and fell down frequently. Then the patient went to the local
hospital (unknown) for examination. After the examination of MRI, the patient
was diagnosed as MS. The doctor told the patient there was no treatment for this
kind of disease, so she took no treatment. In October 2006, the patient began to
be unable to walk, and felt anaesthesia of her double lower limbs. She began to
use wheelchair. Then she started to take our herbal tea by air shipping until
now, and the anaesthesia of her double lower limbs disappeared.
She came to our hospital for further treatment on
April 28,
2007. Since she
got the disease, her spirit, her appetite, and her sleep were all normal.
Her bowel
movement and urination were normal.
Disease
History:
She had
hepatitis A when she was five yeas old, and had cured. No history of typhoid,
tuberculosis, malaria or other infectious diseases. No allergic history of
medicine or food. No operation or trauma history. No history of blood
transfusion. No history of preventive vaccination provided.
Personal History:
She was
born in Lithuania. No contact history of schistosomiasis. No addiction to
alcohol or special food. She has smoked for 15 years, 20 cigarettes a day. She
was even-tempered and open-minded.
Marital History:
She got married at the age of 23. She has given birth to a daughter. Her husband
and her daughter have been healthy all the time.
Menstrual history:
Her
menstrual onset was at her age of 14. Generally, her
menstrual period was 3
to 5 days every 28 to 30 days. Her menelipsis was on March 27, 2003.
Family History:
Her parents are both healthy. No family history of special disease.
Physical Examination:
T 36.4¡æ£¬P
80 beats/minute, R 21 times/minute, BP 110/80 mmHg, K 65 kg.
She grew
normally with common nourishment. Her mind was clear. She had an expression of
chronic illness and languidness. Her body was in a positive posture and she was
cooperative in examination. Her skin was moist. No jaundice in the sclera. No
superficial lymph-node enlargement. Bilateral pupils were round, equal in size
and sensitive to light. No thoracic deformity. Sound of breath was bilaterally
normal on auscultation. No respiratory rales or pleural friction rubs. Heart
border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular.
No pathological murmurs on auscultation.
Abdomen touches flat and soft without tenderness or rebounding tenderness. The
liver and spleen were not palpable. No percussion pains in renal region. Bowel
sound was normal. No spinal and pelvic deformity or tenderness. No deformity or
inflexibility of the double upper limbs. The double lower limbs¡¯ muscular were
suffered from rigidity and weakness. Her ankle-joint of double knees was
spastic with difficulty in movement. Her double lower limbs were obviously weak.
Her muscle strength was Grade ¢ò with
muscle tension hypertonicity. Her anus and pudendum were normal. Other
physiological reflex has not been elicited. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left pulse was week.
Diagnostic
Examination:
Not provided.
First Diagnosis:
TCM diagnosis:
Membra rigidity (Wilting
syndrome)
Symptom
identification:
Depletion and vacuity of the liver and kidneys, and the liver wind entering the
network channels.
WM diagnosis:
1.Multiple sclerosis (MS)
2. Multiple
obsolete cerebral infarctions
First Medical Record
April 28,
2007
Audra, a 50-year-old
female, has suffered from
rigidity and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5 years, and her
condition has been aggravated by disability of walking for 2 years. She was
picked up by our workers in Zhijiang Airport and arrived at Huaihua Red Cross
Hospital for further treatment at 14: 00 p.m. on April 28, 2007.
Essentials for
Diagnosis:
1. The patient has
suffered from
rigidity and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5 years, and her
condition has been aggravated by disability of walking for 2 years.
2. In 2002, the
patient began to feel
rigidity and weakness
of her double limbs¡¯ muscular without any obvious causes. At that time, the
patient paid no attention to it, did no treatment about it. Therefore, the
disease was developing progressively. After three months, she began to walk
unsteadily, and fell down frequently. Then the patient went to the local
hospital (unknown) for examination. After the examination of MRI, the patient
was diagnosed as MS. The doctor told the patient there was no treatment for this
kind of disease, so she took no treatment. In October 2006, the patient began to
be unable to walk, and felt anaesthesia of her double lower limbs. She began to
use wheelchair. Then she began to take our herbal tea by air shipping until now,
and the anaesthesia of her double lower limbs disappeared.
She came to our hospital
for further treatment on
April 28,
2007. Since she
got the disease, her spirit, her appetite, and her sleep were all normal.
Her bowel
movement and urination were normal.
3. T 36.4¡æ£¬P
80 beats/minute, R 21 times/minute, BP 110/80 mmHg, K 65 kg
4.
She grew normally with common nourishment. Her mind
was clear. She had an expression of chronic illness and languidness. Her body
was in a positive posture and she was cooperative in examination.
5.
The double lower limbs¡¯ muscular were
suffered from
rigidity and weakness. Her ankle-joint of double knees was spastic with
difficulty in movement. Her double lower limbs were obviously weak. Her muscle
strength was Grade ¢ò with muscle
tension hypertonicity.
6. No thoracic
deformity. Chest percussion noted resonance. Sound of breath was bilaterally
clear on auscultation. No sound of pleural friction.
7. Diagnostic
examination: Not provided.
Diagnosis Basis:
TCM: The patient has
suffered from
rigidity and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5 years, and her
condition has been aggravated by disability of walking for 2 years. Due to the
depletion and
vacuity of the liver and kidneys, her essence-blood could not nourish her sinews
and vessels. Gradually it formed flaccidity syndrome. The wilting syndrome
resulted in depletion of essence and blood, malnutrition of channel sinew,
deficiency of marrow and limp aching lumbus and knees.
Western Medicine:
The double lower limbs¡¯ muscular were suffered from
rigidity and weakness. Her ankle-joint of double knees was
spastic with difficulty in movement. Her double lower limbs were obviously weak.
Her muscle strength was Grade ¢ò with
muscle tension hypertonicity.
After the examination
of MRI, the patient was diagnosed as MS in the local government hospital.
Diagnostic
Differentiation
TCM: The patient¡¯s
wilting
syndrome should be
differentiated from impediment syndrome.
Wilting
syndrome is
characterized as limp, weak, and emaciated limbs with
muscular atrophy.
A patient suffered from flaccidity syndrome may even become unable to hold an
object or to stand without any support. Besides, the patient¡¯s lower limbs are
more often attracted, though he or she usually has no joint pains. On the
contrary, impediment syndrome is generally characterized as aching pains, fixed
heaviness and inflexibility of sinews and bones, muscles and joints, with
occasional numbness or swelling, though, no paralytic manifestations. They are
not difficult to be distinguished in clinics.
Western Medicine:
Wilting
syndrome should
be differentiated from sequela of apoplexy,
which refers
to the remnant symptoms of different severity of half-body paralysis, inhibited
speech and slack mouth and eyes after curing the apoplexia. It is mainly because
of cerebrovascular accident, cerebral ischemia or by oppressing and moving of
hematoma, cerebral edema, which destroy the function of the brain tissues. For
example, cerebral hemorrhage often occurs in brain capsule, which can cause
lusitropic hemiplegia and the left-brain bleeding accompanied by aphasia. The
diagnosis to the disease is the cerebral vascular accident.
First Diagnosis:
TCM diagnosis:
Membra rigidity
(Wilting syndrome)
Symptom
identification:
Depletion and vacuity of the liver and kidneys, and the liver wind entering the
network channels.
Western
medicine
diagnosis: 1.Multiple Sclerosis (MS)
2. Multiple
obsolete cerebral infarctions
Plans for treatment
strategy and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade II care.
3. Under the care of
a companion.
4. Pleasant diet.
5. Herbal tea (to
fortify and nourish the liver and kidneys, extinguish wind and free the network
channels.) one dosage a day and drink twice.
Prescription: Varied formula of the Major Wind-stabilizing Pill.
Main herbs used in
the herbal tea: baishao (white poney), ajiao (ass hide glue), shengdi (fresh
rehmannia root), etc.
6. Acupuncture and
massage: once a day.
7. Have more medical
examinations if necessary.
Date: April 29,
2007 Time: 9:00 a.m.
Today the patient
complained to Dr. Yang that
her double lower limbs¡¯ muscular were suffered from
rigidity and weakness.
She was unable to walk.
The examination of
the function of her liver and kidneys was normal, and the examination of BS, and
electrolyte
blood-fat were all-normal.
Examination:
T 36.4¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg, K 65 kg.
Her heart and lungs
were normal and her abdomen was soft and flat.
Dr. Yang¡¯s analysis:
1. The patient has
suffered from
rigidity and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5 years, and her
condition has been aggravated by disability of walking for 2 years.
2.
The double lower limbs¡¯ muscular were
suffered from
rigidity and weakness. Her ankle-joint of double knees was spastic with
difficulty in movement. Her double lower limbs were obviously weak. Her muscle
strength was Grade
¢ò
with muscle
tension hypertonicity.
3.
After the examination
of MRI, the patient was diagnosed as MS in her national hospital. Flaccidity
syndrome is characterized as limp, weak, and emaciated limbs with
muscular atrophy.
The patient could not move freely. Due to the
depletion and vacuity of
the liver and kidneys, her essence-blood could not nourish her sinews and
vessels. Gradually it formed flaccidity syndrome. The flaccidity syndrome
resulted in depletion of essence and blood, malnutrition of channel sinew,
deficiency of marrow and limp aching lumbus and knees.
Doctor¡¯s diagnosis:
Depletion and
vacuity of the liver and kidneys, and the liver wind entering the network
channels.
Doctor¡¯s strategy: To fortify and nourish the liver and kidneys, extinguish wind
and free the network channels.
Doctor¡¯s requirement
is to take two dosages of the herbal tea of the same prescription. One dosage a
day and drink twice. Acupuncture and massage for once a day. The patient should
have more medical examinations if necessary.
Date: April 30,
2007 Time: 14:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Today, she had a MRI examination of her brain and neck at No.2 hospital
in Huaihua. The results were as follows: 1. There exists multiple ischemic focus
in the bilateral basal ganglia, bilateral centrum semiovale, bilateral occipital
lobe, the left cerebral peduncle, and double Juxtaventricular. 2. There exist
multiple obsolete cerebral infarctions on her right occipital lobe and bilateral
centrum semiovale. 3. Degeneration of the cervical vertebra. 4. C4/5,
C5/6 protrusion of ntervertebral disc. 5. Degeneration and atrophy of
the cervical vertebra. According to above disease information, it is sure that
the diagnosis of TCM is correct. The patient should continue the treatment to
fortify and nourish the liver and kidneys, extinguish wind and free the network
channels, accompanied by the treatment of acupuncture and massage.
Date: May 1,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs were normal, and
her abdomen was soft and flat. The examination of her double lower limbs was the
same as before. Her spirit, her appetite, and her sleep were all normal. Her
bowel movement and urination were normal. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left pulse was weak.
Doctor¡¯s requirement is to take three dosages of the herbal tea of the same
prescription. One dosage a day and drink twice.
Date: May 5,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs were normal, and
her abdomen was soft and flat. The examination of her double lower limbs was the
same as before. Her spirit, her appetite and her sleep were all normal. Her
bowel movement and urination were normal. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left pulse was week.
Doctor¡¯s requirement is to take herbal tea of the same prescription. One dosage
a day and drink twice.
Date: May 8,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs were normal, and
her abdomen was soft and flat. The examination of her double lower limbs was the
same as before. Her spirit, her appetite and her sleep were all normal. Her
bowel movement and urination were normal. Her tongue was red with thin and white
tongue coating. Her right pulse was slippery and her left pulse was week.
Doctor¡¯s requirement is to take herbal tea of the same prescription. One dosage
a day and drink twice.
Date: May 13,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs were normal, and
her abdomen was soft and flat. The examination of her double lower limbs was the
same as before. Her spirit, her appetite and her sleep were all normal. Her
bowel movement and urination were normal. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left pulse was week.
Doctor¡¯s requirement is to take five dosages of the herbal tea of the same
prescription. One dosage a day and drink twice.
Date: May 18,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs were normal, and
her abdomen was soft and flat. The examination of her double lower limbs was the
same as before. Her spirit, her appetite and her sleep were all normal. Her
bowel movement and urination were normal. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left pulse was week.
Doctor¡¯s requirement is to take herbal tea of the same prescription. One dosage
a day and drink twice.
Date: May 22,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs were normal, and
her abdomen was soft and flat. The examination of her double lower limbs was the
same as before. Her spirit, her appetite and her sleep were all normal. Her
bowel movement and urination were normal. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left pulse was week.
Doctor¡¯s requirement is to take five dosages the herbal tea of the same
prescription. One dosage a day and drink twice.
Date: May 27,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.7¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her heart and lungs were normal, and her abdomen was soft and flat.
The examination of her double lower limbs was the same as before. Her spirit,
her appetite and her sleep were all normal. Her bowel movement and urination
were normal. Her tongue was dull with thin and white tongue coating. Her right
pulse was slippery and her left pulse was week. Doctor¡¯s requirement is to take
herbal tea of the same prescription. One dosage a day and drink twice.
Summary Stage
Date: May 28,
2007 Time: 10:00 a.m.
Audra, a 50-year-old
female, has suffered from
rigidity and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5 years, and
hercondition has been aggravated by disability of walking for 2 years. She was
picked up by our workers in Zhijiang Airport, and she arrived at Huaihua Red
Cross Hospital for further treatment at 14: 00 p.m. on April 28,
2007.
Physical examination:
T 36.7¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg, K 65 kg.
She
has developed normally with medium nutrition.
Her mind was clear. She has an expression of chronic illness and languidness.
She was in a positive posture and cooperative in examination. Her heart and
lungs were normal, and her abdomen was soft and flat.
The double lower limbs¡¯ muscular were
suffered from rigidity and weakness. Her ankle-joint of double knees was
spastic with difficulty in movement. Her double lower limbs were obviously weak.
Her muscle strength was Grade
¢ò
with muscle tension
hypertonicity. Her spirit, her appetite and her sleep were all normal. Her bowel
movement and urination were normal.
First diagnosis:
TCM diagnosis:
Membra rigidity
(flaccidity syndrome)
Symptom
identification:
Depletion and vacuity of the liver and kidneys, and the liver wind entering the
network channels.
Western
medicine diagnosis: Multiple Sclerosis (MS)
The process of treatment: the patient has taken our herbal tea to
fortify and nourish the liver and kidneys, to extinguish wind and free the
network channels
since she arrived at our hospital. The prescription:
One dosage a day and
drink twice. Take 100ml herbal tea each time. Do the treatment of acupuncture
and massage once a day. The patient¡¯s health condition was becoming better.
The current
situation: Her
spirit, her appetite and her sleep were all normal. Her bowel movement and
urination were normal.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg, K 65 kg.
Her heart and lungs were normal, and her abdomen was soft and flat.
She suffered
from the muscular rigidity and
weakness of the lower limbs. Her ankle-joint of double knees was spastic with difficulty in
movement. Her double lower limbs were obviously weak. Her muscle strength was
Grade
¢ò
with muscle
tension hypertonicity. Her tongue was light red with thin and white tongue
coating. Her pulse was slippery.
Current diagnosis:
TCM diagnosis:
Membra rigidity
(flaccidity syndrome)
Symptom
identification:
Depletion and vacuity of the liver and kidneys, and the liver wind entering the
network channels.
Western
medicine diagnosis: Multiple Sclerosis (MS)
Plans for treatment
strategy and nursing:
1. Continue taking
herbal tea to fortify and nourish the liver and kidneys, extinguish wind and
free the network channels.
2. Acupuncture and
massage: once a day.
3. Take exercise of
the function of the double lower limbs once a day.
4. Keep open-minded
mood and pleasant spirit.
Date: June 2,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit, her appetite and
her sleep were all normal. Her bowel movement and urination were normal. Her
tongue was dull with thin and white tongue coating. Her pulse was slippery.
Doctor¡¯s requirement is to take herbal tea of the same prescription. One dosage
a day and drink twice.
Date: June 7,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her heart and
lungs were normal, and her abdomen was soft and flat. The examination of her
double lower limbs was the same as before. Her spirit, her appetite and her
sleep were all normal. Her bowel movement and urination were normal. Her tongue
was dull. Her pulse was slippery. Doctor¡¯s requirement is to take five dosages
of the herbal tea of the same prescription. One dosage a day and drink twice.
Date: June 12,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit, her appetite and
her sleep were all normal. Her bowel movement and urination were normal. Her
tongue was dull. Her pulse was slippery. Doctor¡¯s requirement is to take herbal
tea of the same prescription. One dosage a day and drink twice.
Date: June 17,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit, her appetite and
her sleep were all normal. Her bowel movement and urination were normal. Her
tongue was dull. Her pulse was slippery. Doctor¡¯s requirement is to take herbal
tea of the same prescription. One dosage a day and drink twice.
Date: June 22,
2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit, her appetite and
her sleep were all normal. Her bowel movement and urination were normal. Her
tongue was dull. Her pulse was slippery. The patient would leave the hospital
today.
