Records of Hospitalization

Name: Arun                                                     Sex: Male

Nationality: India                                             Age: 11  

Marital status: Unmarried                               Date of Admission: Apr. 22nd, 2007

Onset Season: Summer                                 Date of Report: Apr. 22nd, 2007

Complainer : The patients father                   Reliability: Reliable

Major complaints: The patient has suffered from lower limb weakness and lame walking four years accompanied by an aggravated duck-gait for two years.

Present illness:

At the end of 2003, the patient had a change in walking posture without any evident predisposing cause. He began to slow down his walking speed and felt weakness on his lower limbs. At that time, his family neither paid much attention on his condition, nor took him to do any examination and treatment. In 2005, the patients condition was aggravated. He had difficulties in walking without balance and often fell down. He needed to turn over and slowly picked himself up when he was spinning in bed.  He walked with duck-gait posture. He was taken to a local hospital and got the definite diagnosis for with Progressive muscular dystrophy (DMD) by MRI test. The doctor told him there was no therapeutic schedule for this disease, so he was not given any treatment until now. He was picked up by our workers and arrived in Huaihua Red Cross Hospital for treatment on April 22nd, 2007. The patient has good spirit, appetite and sleep. His bowel movement and urination are normal.

Past history: No history of typhoid, tuberculosis or hepatitis. No history of food or medicine allergy. No history of operation or blood transfusion.  On April 29th, 1998, he was given BCG vaccination.

Personal history: He was born in India. He is the first child by natural delivery. He lives in a dry environment. No contact history of schistosomiasis. No addiction to alcohol, smoking or special food. He is calm and cheerful.

Marital history: Unmarried.

Family history: No family history of special disease.

Physical examination

T 36.3棬P 88bpm, R 24bpm, BP: 100/70mmHg, W 37.5kg.

He is mid-nourished and normally developed. His mind is clear. Chronic face mirroring difficult condition. Languor expression, in a positive position and cooperative in examination. His skin is moist. No jaundice in the sclera. No superficial lymph-node enlargement. Bilateral pupils are round, equal in size and sensitive to light. No thoracic deformity. Sound of breath is bilaterally normal on auscultation. No respiratory rales or pleural friction rubs. Heart border is not big. Heart beat 98bpm. Cardiac rhythm is regular. No pathological murmurs of heart on auscultation. Abdomen is flat and soft without tenderness or rebound tenderness. Liver and spleen are not palpable. No percussion pain on renal region. Bowel sound is normal. No Spinal and pelvic deformity or tenderness. Both upper limbs have no deformity and normal mobility. The patient has suffered from lame walking accompanied by a duck-gait. He can not run and has difficulties in stepping up the stairs. He often falls down. He has to turn over when lying face upward and used his two hands holding his knees to slowly rise upward. Both side of his gastrocnemius are hypertrophic and hard. The myodynamia of his lower limbs are grade III and myatonia. Straight leg raising test: left leg is 5 degrees and the right leg is 5 degrees.  The development of the anus or genital is normal. Physiological reflex has not been elicited. Red tongue, thin and white tongue fur, fine and deep pulse.

Accessory examination: Not provided yet.

First diagnosis: TCM diagnosis: Wei-syndrome (flaccidity syndrome)

Symptom diagnosis: Spleen and stomach asthenia; liver and kidney asthenia.

WM diagnosis: Progressive muscular dystrophy (DMD).