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Brief Summary:
On July 7, 2007, the MS patient Hanen from Saudi Arabia, who
suffered from weakness and numbness of the lower limbs and unsteady
walking, was hospitalized at our hospital. After 20-day TCM treatment,
she has achieved significant improvement. She was very satisfied with
the Chinese medicine treatment.
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Record of
Hospitalization
Name:
Hanen Sex: Female
Age:
21
Profession: Student
Nationality:
Saudi Arabia
Marital Status: Unmarried
Onset Season:
Summer
Date of Admission: July 7, 2007
Complainer:
The patient¡¯s herself Reliability: Reliable
Major Complaint:
The patient has suffered from weakness and numbness of the lower limbs for 4
years, and her condition has been aggravated by unsteady steps for one month.
Present Illness:
In July 2003, the patient began to feel weakness and numbness of the lower limbs
without any obvious causes, and the condition lasted for two weeks. At that
time, the patient paid no attention to it, and did no treatment about it. A
month later, the weakness and numbness of her lower limbs were aggravated, and
then she went to a local hospital (unknown) for a diagnosis. After the
examination, the patient was diagnosed with MS. The hospital gave her the
treatment of ¡°interferon
injection¡± for once every other day and prescribed ¡°ceftiofur sulfur
trimethylamine¡± for orally taking 150mg each time and twice a day. The patient¡¯s
condition was controlled. In June 2007, the patient¡¯s condition was suddenly
aggravated. There appeared
diplopia
on her eyes.
The weakness and numbness of her lower limbs were aggravated. She had difficulty
in walking with unsteady steps, and she always fell down if no support was
offered. She could not crouch or stand up. Then she went to a local hospital
(unknown) for treatment, and was prescribed six days¡¯ cortisone for orally
taking. She got some improvement, and her eyes¡¯ diplopia disappeared. To seek
further comprehensive treatment, she was picked up by our staff to our hospital
at 19:00 p.m. on July 7, 2007. Since she got the disease, her spirit
and appetite have been both normal with slightly poor sleep.
In a recent month,
she had urinary
incontinence with once bowel movement every three days.
Disease History:
No history
of typhoid, tuberculosis, hepatitis, malaria
or other infectious diseases.
No allergic history of medicine or food. No operation or
trauma
history. No history of preventive vaccination provided.
Personal History:
She was born in
Saudi Arabia,
living in a dry environment. No contact history of schistosomiasis. No addiction
to smoking, alcohol or special food. She was mild-tempered and open-minded.
Marital History:
She has
not been married yet.
Menstrual History:
Her
menstruation started at the age of 12. Generally, her
menstrual period was
five to six days every 28 to 30 days. Her last menstruation was on June 29,
2007. Her menses is in red with little amount, without any abnormal smell.
Family history: Her
parents were both healthy. No family history of special disease.
Physical Examination:
T 36.3¡æ£¬P
78 beats/minute, R 18 times/minute, BP 120/80 mmHg,.
She grew normally
with medium nutrition. 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 and 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 touched flat and soft
without tenderness or rebounding tenderness. Liver and spleen were not palpable.
No percussion pain in renal region. Bowel sound was normal. No spinal and pelvic
deformity or tenderness. No deformity or inflexibility of the upper limbs. The
lower limbs were suffering from weakness and numbness.
She could not crouch or stand up, accompanied by
unsteady walking. The
Romberg levy was (+).
Her muscle
strength of the lower limbs was Grade
¢ó
with muscular tension
weakened.
The examinations of anus and pudendum were both normal. The
brinell levy was
normal. Other physiological
reflex has not been elicited. Her tongue was dull with yellow tongue coating.
Her pulse was string-like and slippery.
Diagnostic
examination: Not provided.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom diagnosis:
Deficiency of the liver and kidneys, liver wind entering network channels with
qi vacuity.
Western medicine
diagnosis:
Multiple sclerosis (MS)
First Medical Record
July 7,
2007
Hanen, a 21-year-old
female, has suffered from weakness and numbness of the lower limbs for 4 years,
and her condition has been aggravated by unsteady steps for one month. She was
picked up by our staff at Zhijiang airport, and arrived in Huaihua Red Cross
Hospital for further treatment at 19: 00 p.m. on July 7, 2007.
Essentials for
diagnosis:
1. The patient has
suffered from weakness and numbness of the lower limbs for 4 years, and her
condition has been aggravated by unsteady steps for one month.
2. In July 2003, the
patient began to feel weakness and numbness of the lower limbs without any
obvious causes, and lasted for two weeks. At that time, the patient paid no
attention to it, and did no treatment about it. A month later, the weakness and
numbness of her lower limbs were aggravated, and then she went to a local
hospital (unknown) for a diagnosis. After the examination, the patient was
diagnosed with MS. The hospital gave her the treatment of ¡°interferon
injection¡± for once every other day and prescribed ¡°ceftiofur sulfur
trimethylamine¡± for orally taking 150 mg each time and twice a day. The
patient¡¯s condition was controlled. In June 2007, the patient¡¯s condition was
suddenly aggravated. There appeared
diplopia
on her eyes.
The weakness and numbness of her lower limbs were aggravated. Besides, she had
difficulty in walking with unsteady steps, and she always fell down if no
support was offered. She could not crouch or stand up, and she had urinary
incontinence. She went to a local hospital (unknown) for treatment, and was
prescribed six days¡¯ cortisone for orally taking. She got some improvement, and
her eyes¡¯ diplopia disappeared. To seek further comprehensive treatment, she was
picked up by our staff to our hospital at 19:00 p.m. on July 7, 2007.
Since she got the disease, her spirit and appetite have been both normal with
slightly poor sleep.
In a recent month,
she had urinary
incontinence with once bowel movement every three days.
3. T 36.3¡æ£¬P
78 beats/minute, R 18 times/minute, BP 120/80 mmHg,.
4. She grew normally
with common nutrition. 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 with clear mind.
5.
The lower limbs were suffering from
weakness and
numbness. She could not crouch or stand up, and her condition was accompanied by
unsteady walking. The
Romberg levy was (+).
Her muscle
strength of the lower limbs was Grade
¢ó
with muscular tension
weakened.
The brinell
levy was normal.
6. No thoracic
deformity. Chest percussion noted resonance. Sound of breath is bilaterally
clear on auscultation. No sound of pleural friction rubs.
7. Diagnostic
examination: Not provided.
Diagnostic Basis:
TCM:
The patient has suffered from weakness and numbness of the lower limbs for 4
years, and her condition has been aggravated by
unsteady steps for one month. The patient had
deficiency of the liver and kidneys. The essence-blood could not nourish the
muscles and vessels. Gradually it resulted in flaccidity syndrome. The loins are
the residence of the kidneys, and the kidneys are in charge of the bones. The
insufficiency of essence-marrow makes limbs wilting and makes the loins and
knees weak. Her tongue was dull with yellow tongue coating. Her pulse was
string-like and slippery. All these reflections belong to the scope of
flaccidity syndrome.
Western medicine:
The patient has suffered
from weakness and numbness of the lower limbs for 4 years,
and her condition has been aggravated by unsteady
steps for one month.
The lower limbs were suffering from
weakness and
numbness. She could not crouch or stand up. Besides, she walked unsteadily. The
Romberg levy
was (+). Her
muscle strength was Grade
¢ó
with muscular tension
weakened.
The patient
was diagnosed with MS in her national hospital (unknown).
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
wilting
syndrome may even become unable to hold an object or to stand without any
support. Besides, the patient¡¯s lower limbs are more often affected, though she
usually has no joint pains. On the contrary, impediment syndrome is generally
characterized by aching pains, fixed heaviness and inflexibility of the sinews,
bones, muscles and joints, with occasional numbness or swelling, though, no
paralytic manifestations exist. They are not difficult to be distinguished in
clinics.
Western Medicine: Wilting syndrome
should be differentiated from myasthenia gravis, which is a kind of acquired
autoimmune disease that there appear transmitting obstacles in the
site of neuromuscular junctions
owing to the reduced acetylcholine receptor. Myasthenia gravis can
occur at any age and there are about 60 percent people stricken before 30 years
old. Women are more often affected than men are.
The most obvious characteristic of
MG is rapid fatigability and weakness of the
striated
muscles.
It will be improved with rest or medicines that
inhibit the activity of cholinesterase.
It can also involve
cardiac muscles and
smooth muscles.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification:
Deficiency of the liver and kidneys, liver wind entering network channels with
qi vacuity.
Western medicine
diagnosis: MS
Plans for treatment
strategy and nursing:
1. On routine care of
traditional Chinese internal medicine.
2. On grade II care.
3. Under the care of
a companion.
4. Regular diet.
5. Herbal tea (to
supplement and boost liver and kidneys,
to boost qi, to track down wind
and to free the network channels): one dosage a day and drink twice.
Prescription: Varied
formula of the Hidden Tiger Pill.
Main herbs used in
the herbal tea: huangqi (astragalus root), shudi (cooked rehmannia root), gouqi
(lycium), etc.
6. Acupuncture and
massage: once a day.
7. Western medicine:
Interferon
injection (self-prepared) for twice a day;
8. Have more medical
examinations if necessary.
Date: July 8,
2007 Time: 9:00 a.m.
The
patient did
not complain about any other special discomfort
to Dr. Yang, but she had
weakness and numbness of the lower limbs, accompanied by unsteady walking.
Examination:
T 36.4¡æ,
P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat.
Dr. Yang¡¯s analysis:
1. The patient has
suffered from weakness and numbness of the lower limbs for 4 years, and her
condition has been aggravated by unsteady steps for one month.
2.
The lower limbs were suffered from
weakness and numbness. She could not crouch or stand up. Besides, she walked
unsteadily. The Romberg levy was (+). Her muscle strength of the lower limbs was
Grade ¢ó with muscular tension
weakened. Her tongue was dull with yellow tongue coating. Her pulse was
string-like and slippery.
3. In August 2003,
the patient was diagnosed with MS in a national hospital (unknown). According to
the above information, TCM diagnosed it as wilting syndrome which is
characterized as
retardation of the
limbs¡¯ muscles and vessels, weakness of the limbs, difficulty in movement,
accompanied by muscular atrophy. In clinics, this kind of disease affects lower
limbs more often, which is also called ¡°crippling wilting¡±. The patients who are
suffering from it feel weakness of the spleen and stomach, lack of sources of
the qi and blood, which could not nourish the muscles and vessels, and so it
forms wilting limbs. The
kidneys are in charge of the bones. The insufficiency of essence-marrow makes
the limbs wilting and makes the lumbus and knees weak.
Doctor¡¯s diagnosis:
Insufficiency
of the liver and kidneys, and liver wind entering the network channels with qi
vacuity.
Doctor¡¯s strategy: supplementing and boosting the liver and kidneys, boosting qi,
extinguishing wind and freeing the network channels.
Varied formula of the
Hidden Tiger Pill.
Doctor¡¯s requirement
is to take six dosages of the herbal tea of the same prescription. One dosage a
day and drink twice. Acupuncture and massage for once a day.
Western medicine:
Interferon
injection (self-prepared) for twice a day. The patient should have more medical
examinations if necessary.
Date: July 9,
2007 Time: 9:00 a.m.
Today the patient did
not complain about any other special discomfort and still felt the
weakness and numbness
of her lower limbs, accompanied by
unsteady walking.
The examinations of
the blood and the function of her liver and kidneys were all normal;
six items of
hepatitis B and B.S were all normal.
The examinations of ECG and
the lungs were both normal. Her heart and lungs were normal, and her abdomen was
soft and flat.
Her spirit and diet
were both normal. Her sleep was good. She was with
urinary incontinence. Her
bowel movement was
normal. Doctor¡¯s requirement is that the herbal tea should follow the original
formula.
Date: July 10,
2007 Time: 10:00 a.m.
Today the patient did
not complain about any other special discomfort and still felt the
weakness and numbness
of her lower limbs, accompanied by
unsteady walking. The examinations of
her stool and urine were both
normal. Examination:
T 36.3¡æ,
P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat.
Her spirit and diet were both normal. Her sleep was good. Her
urinary incontinence got some
improvement. Her
bowel movement was
normal. Doctor¡¯s requirement is that the herbal tea should follow the original
formula.
Date: July 14,
2007 Time: 9:00 a.m.
Today the patient did
not complain about any other special discomfort. The
weakness
of her lower limbs was improved,
still with numbness, and her unsteady walking got some improvement.
Examination:
T 36.4¡æ,
P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat.
Her spirit and diet were both normal. Her sleep was good. Her
urinary incontinence almost
disappeared. Her
bowel movement was
normal. Her tongue was dull with yellow tongue coating. Her pulse was
string-like and slippery. Doctor¡¯s requirement is to take three dosages herbal
tea of the same prescription. One dosage a day and drink twice. The herbal tea
should follow the original formula.
Date: July 18,
2007 Time: 9:30 a.m.
Today the patient did
not complain about any other special discomfort. The
weakness
of her lower limbs was improved,
still with numbness, and her unsteady walking got obvious improvement.
Examination:
T 36.4¡æ,
P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat.
Her spirit and diet were both normal. Her sleep was good.
Her
bowel movement and
urination were both normal. Her tongue was dull with yellow tongue coating. Her
pulse was string-like and slippery. Doctor¡¯s requirement is that the herbal tea
should follow the original formula.
Date: July 22,
2007 Time: 9:30 a.m.
Today the patient did
not complain about any other special discomfort. The
weakness
of her lower limbs was improved, the
numbness of the lower limbs almost disappeared, and her unsteady walking got
obvious improvement.
Examination:
T 36.4¡æ£¬P
78 beats/minute, R 18 times/minute, BP 120/80 mmHg.
Her heart and lungs were normal,
and her abdomen was soft and flat.
Her spirit and diet were both normal. Her sleep was good.
Her
bowel movement and
urination were both normal. Her tongue was dull with yellow tongue coating. Her
pulse was string-like and slippery. Doctor¡¯s requirement is that the herbal tea
should follow the original formula.
Date: July 26,
2007 Time: 9:30 a.m.
Today the patient did not complain about any other special discomfort. The
weakness of her lower limbs was improved,
the numbness of the lower limbs disappeared, and her unsteady walking achieved
obvious improvement.
Examination:
T 36.4¡æ£¬P
78 beats/minute, R 18 times/minute, BP 120/80 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat.
Her spirit and diet were both normal. Her sleep was good.
Her
bowel movement and urination were both normal. Her tongue was dull with yellow
tongue coating. Her pulse was string-like and slippery. The patient would leave
the hospital tomorrow.
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