Brief Summary: On Jan. 20, 2009, Rodica, from Romania, who has suffered from MS, accompanied with the symptoms of the weakness and pains of the lower limbs for 2 years, was hospitalized in our hospital. She has achieved significant improvement after 42 days TCM treatment here, and she said that she had got 85% improvement.

 

Record of Hospitalization

Name: Rodica                                                                                                       Birthplace: Romania

Sex: Female                                                                                                           Profession: Doctor

Age: 52                                                                                                                 Date of Admission: Jan. 20, 2009

Nationality: Romania                                                                                            Date of Record: Jan. 21, 2009

Marital Status: Married                                                                                        Onset Season: Great Cold

Complainer: The patient herself

 

First Medical Record

Date: Jan. 20, 2009                                      Time: 19: 00 p. m.

Rodica, a 52-year-old female, has suffered from the weakness and pains of the lower limbs for 2 years. It became more serious for one month. She was hospitalized in our hospital for treatment on Jan. 20, 2009.

Essentials for Diagnosis:

1. The patient has suffered from the weakness and pains of the lower limbs for 2 years. It became more serious for one month.

2. Three years ago, she began to feel fever (T 38≧) and chills for four days due to tiredness. She had the symptom of fever for 3-4 times every year. At that time, she was given intravenous drip to ally the fever. Two years ago, she felt stabbing pains of the right heel, the joints of right leg and the muscles without obvious reasons. Besides, there were symptoms of the numbness and pains of her right fingers and right wrist joints. Then she was given the medicines for treatment, but there was no improvement. Last October, she was given MRI examination in USA which showed that she had the damage of brain white matter. Her present symptoms were as follows: dizziness, insomnia, night sweating, sour belching, increased eating with rapid hungering and weight increasing from 70 kg to 86 kg. She didn¨t feel mouth dry and bitter. She was fond of warm water. Besides, she had constipation and deep yellow urine.

3. She had metrofibroma and double vision in the past, but without hepatitis, tuberculosis, AIDS, etc.

4. T 36.4≧, P 88 times/minute, R 20 times/minute, BP 140/90mmHg.

5. She grew normally with excess nutrition. She seemed to be of a little over-weight. Her mind was clear. She had natural expression. Her body was in a positive posture and she was cooperative with clear mind. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 88 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation. There were no tapping pains in the area of the liver and kidneys. Her abdomen was flat and soft. There was no pressing pains and rebound tenderness. Muscle tendon reflex existed, and the examination of nervous system was normal.

Diagnostic Basis:

TCM: The patient has typical symptoms of the weakness and pains of the lower limbs, so she is diagnosed with wilting pattern. Wind-cold-damp evil results in obstruction of the channels and network vessels as well as joints, so qi and blood cannot move smoothly, and then the patient feels heavy aching pains. Due to malnutrition of qi and blood, the patient can feel the numbness of the sinews and joints. Intense stomach fire, increased eating with rapid hungering and stomach fire shifting to the large intestine result in constipation. Because of excess tiredness, the patient feels dizziness and insomnia. There are teeth marks on the edges of the tongue. She has thin and white tongue coating, thready and rapid pulse. These conditions are the manifestation of disharmony of qi and blood as well as obstruction of the channels and network vessels due to cold-damp.

Western Medicine:

1. The patient has suffered from the weakness and pains of the lower limbs for 2 years. It became more serious for one month.

2. Last October, she was given MRI examination in USA which showed that she had the damage of brain white matter.

Diagnostic Differentiation:

TCM: The patient's wilting pattern should be differentiated from impediment pattern. Wilting pattern is mainly characterized by limp, weak and emaciated limbs with the numbness of the muscles. However, impediment pattern is generally characterized by joint pains. So they are not difficult to be distinguished.

Western Medicine: MS should be differentiated from apoplexy sequelae. Stroke is a kind of paroxysmal disease, accompanied by the symptoms dizziness, etc. It is characterized by paralysis of one side of the body, but there are no obvious joint pains. The disease can be diagnosed definitely by MRI examination.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Wilting pattern

Symptom identification: Disharmony of qi and blood, obstruction of the channels and network vessels due to cold-damp.

Western Medicine: Multiple Sclerosis

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Low-fat and high-protein diet.

4. Acupuncture and massage: once a day.

5. Strengthen the functional exercise of the four limbs.

6. Herbal tea: one dosage a day and drink twice.

Main herbs used in the herbal tea: chuanxiong (ligusticum root), danggui (tangkuei), honghua (carthamus flower), etc. 3 dosages in total.

 

Date: Jan. 23, 2009                                       Time: 10: 00 a. m.

The patient said her sleep and diet were normal. In recent two days, she felt pains in the throat. So yesterday the doctor gave her some herbal medicine to take, today she felt a little better. The pains of the lower limbs also lessened. The prescription was changed a little. 3 dosages in total.

 

Date: Jan. 26, 2009                                       Time: 10: 00 a. m.

Her sleep and diet both were normal. The pains in her throat disappeared, but she had dry cough for 2 days. She could move quickly from sitting position to standing position. There were no pains of the lower limbs. The patient thought there was obvious improvement. The prescription was changed. 3 dosages in total.

 

Date: Jan. 29, 2009                                       Time: 11: 00 a. m.

The patient said that there were slight pains in her left ankle joint after 2 hours walking on Jan. 27. Compared with before, the degree of the pains was just 40%. She believed this condition was a good change. Yesterday she felt her body was relaxed when she did different kinds of body movement in the room, but there were pains in her left ankle joint when she moved from sitting position to standing position. But she said the degree of the pains was just 40% compared with before. She was satisfied with the change. Her cough basically disappeared. Every night she could sleep 4-6 hours. The patient hoped that the quality of her sleep could improve. So the doctor added some herbs for quieting the spirit to improve her sleep. 3 dosages in total.

 

Date: Feb. 1, 2009                                       Time: 10: 00 a. m.

The patient said the pains all over the body basically disappeared. There are only slight pains on her neck. She felt her body was relaxed. Her sleep also improved. In recent two days, she could sleep about 7 hours. Her urine and bowel movement both were normal. So the doctor made a little adjustment of the former prescription. 4 dosages in total.

 

Date: Feb. 5, 2009                                       Time: 10: 00 a. m.

There was no obvious discomfort. Yesterday her sleep was not good. She slept about 5 hours. The other condition was normal. The former prescription was nearly the same as Feb. 1. 4 dosages in total.

 

Date: Feb. 9, 2009                                       Time: 10: 00 a. m.

Her spirit and sleep were normal. Yesterday she slept 7-8 hours. She felt slight pains of the neck when she played computer for a long time. Sometimes there was slight discomfort in her left thenar. Besides, she felt mouth dry. She was fond of drinking much water. The other condition was normal. 4 dosages in total.

 

Date: Feb. 11, 2009                                      Time: 16: 00 p. m.

The feedback of blood-fat examination was as follows: CH 6.3 mmol/L, TG 3.2 mmol/L and HDL-C 0.6mmol/L.

 

Date: Feb. 13, 2009                                      Time: 11: 00 a. m.

Her spirit and sleep were normal. Her urine and bowel movement were also normal. There was still slight discomfort in her left thenar. The former prescription was changed. 4 dosages in total.

 

Date: Feb. 17, 2009                                      Time: 10: 30 a. m.

She could not sleep very well last night. The other condition was normal. There was slight change of the former prescription. 4 dosages in total.

 

Date: Feb. 21, 2009                                      Time: 10: 00 a. m.

The patient said the pains of her knee joint, ankle, etc. obviously lessened. Her urine and bowel movement were normal. She complained that her sleep was not good because she just slept 5-6 hours last night. She said that she had got 85% improvement. The other condition was normal. So the previous prescription was made a little adjustment. 4 dosages in total.

 

Date: Feb. 25, 2009                                      Time: 10: 00 a. m.

Sometimes there was occasional discomfort of her knee joint, ankle, etc. The other condition was normal. Continue to take the former prescription. 3 dosages in total.

 

Date: Mar. 3, 2009                                       Time: 10: 00 a. m.

She decided to leave the hospital tomorrow.

　

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