Records of Hospitalization
Name:
Abdullah
Sex:
Male
Age:
55
Nationality:
Saudi Arabia
Marital status:
Married Onset
Season:
Summer
Date
of Admission:
Feb. 26, 2007
Date of Recoding:
Feb. 26, 2007
Complainer of history:
The patient himself Reliability:
Reliable
Major
complaint:
The patient was suffering from body trembling accompanied by an aggressive
weakness for one year.
Present illness:
Eleven years ago, without any obvious cause, the patient began to have
dizziness, dreaminess, slow response and a little bit body trembling. At that
time, he hadn¡¯t done anything about his illness due to ignorance, it
progressively grew worse. In February, 2006, the patient¡¯s whole body trembling
aggravated. He got starting difficult, slow movement and response. Tonus on his
four limbs increased and he felt asthenia from the head to foot. He checked in a
local hospital (not in detail) and the diagnosis for him is Parkinson¡¯s disease.
The doctors in the hospital gave him L-dopa (3 times a day and each time 250mg)
which belongs to dopamine drugs and amantadine (twice a day and each time 150mg)
for orally taken until now. Because he had no obvious improvement on his disease
condition, he came to hospitalize in our Traditional Chinese Medicine (TCM)
Department. Since he has the disease, his spirit was a little worse; his
appetite was good, but the quality of his sleep was bad; his bowel movement and
urination were normal.
Past
history:
He was quite health before. No history of typhoid, tuberculosis, diarrhea and
hepatitis. No history of medicine or food allergy. No history of traumatism or
operation. No history of preventive vaccination
provided.
Personal history:
He was born in Saudi Arabia. No contact history of schistosomiasis. He had
regular diet and sleep. No addiction to alcohol or smoking.
Marital history:
He married at 23 and has a daughter and a son.
His wife and children are all healthy.
Family
history:
No family history of the similar or other special disease.
Disease statement:
From the patient himself. Consider it was reliable.
Physical examination
T: 36.5¡æ£¬P:
78bpm, R: 20bpm, BP: 115/75mmHg
He is
mid-nourished and normally developed. His mind is clear. He is in a positive
position and cooperative in examination. His skin and sclera have no jaundice.
His head, facial features are normal. Bilateral pupils are round and symmetrical
in size and sensitive to light. No purulence from the external auditory canal.
No flaring of alaenasi. No cyanopathy in his lips and no reddish in the pharynx.
No swelling of the tonsil. Soft neck and middle placed trachea. No swelling of
the thyroid gland. No thoracic deformity. His respiratory movement is smoothly.
Bilateral of his vocal fremitus are normal. Percuss sounds clear. Sound of
breath is bilaterally normal on auscultation. No respiratory rales or pleural
friction rubs. Heart border is normal. Heart beat 78bpm. 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. The anus and pudendum have not been checked.
No Spinal deformity. He can move freely. He
has obviously whole body trembling, starting difficult, slow movement and
response. Tonus on his four limbs increased and he feels asthenia from
the head to foot. He has dizziness and dreamful sleep. The pathological signs
are not elicited out. Light red tongue, white and thin tongue fur, fine and deep
pulse.
Accessory examination:
It is vacant
at the moment.
First
diagnosis:
TCM diagnosis:
Trembling and numbness.
Symptom diagnosis:
Enrich the
liver and kidney, extinguish wind and quicken the network vessels.
WM
diagnosis:
Parkinson¡¯s
disease.
Dr. Yan
Zaoming/ Dr. DaiLei
First Medical Record
Abdullah, a
55-year-old male, has been suffering from whole body trembling for about 11
years accompanied by an aggravated acratia for one year. He was received by our
staff in Zhijiang Airport and arrived at our Huaihua Red Cross Hospital on
February 26, 2007.
Case
characteristics:
1.
He has
suffered from whole body trembling about 11 years accompanied by an aggravated
acratia for one year.
2.
Eleven years
ago, without any obvious cause£¬
the patient began to have dizziness, dreamful sleep, slow
response and a little bit whole body trembling. At that time, because he hadn¡¯t
done any examination and treatment about his illness due to ignorance, it
progressively grew worse. In February, 2006, the patient¡¯s whole body trembling
aggravated. He got starting difficult, slow movement and response. Tonus on his
four limbs increased and he felt asthenia from head to foot. He checked in a
local hospital (not in detail) and the diagnosis for his disease was Parkinson¡¯s
disease. The doctor in the hospital gave him L-dopa (3 times a day and each time
250mg) which belongs to dopamine drugs and amantadine (two times a day and each
time 150mg) for orally taken until now. Because he had no obvious improvement on
his disease condition, he came to hospitalize in our Traditional Chinese
Medicine (TCM) Department. Since he has the disease, his spirit is a little
worse; his appetite is good, but the quality of his sleep is bad; his bowel
movement and urination are normal.
3. T: 36.5¡æ£¬P:
78bpm, R: 20bpm, BP: 115/75mmHg
4. He is
mid-nourished and normally developed. His mind is clear, chronic face mirroring
difficult condition, languor expression. He is in a positive position and
cooperative in examination.
5.
He has obviously whole body trembling,
starting difficult, slow movement and response. Tonus on his four limbs
increased and he feel asthenia from head to foot. He has dizziness and dreamful
sleep.
6. Bilateral
of his vocal fremitus are normal. Percuss sounds clear. Sound of breath is
bilaterally normal on auscultation. No respiratory rales or pleural friction
rubs.
7. Accessory
examination: It is vacant at the moment.
Diagnosis
TCM:
He has been suffering from whole body trembling for about 11 years accompanied
by an aggravated acratia for one year. The disease is onset slowly after the
middle or old aged people. He has obvious whole body trembling, starting
difficult, slow movement and response. Tonus on his four limbs increased and he
feels asthenia from head to foot. He has dizziness and dreamful sleep. The
pathogenesis of this disease is liver-kidney yin depletion.
Western medicine:
He has suffered from whole body trembling about 11 years accompanied by an
aggravated acratia for one year. The disease is onset slowly. He has obvious
whole body trembling, starting difficult, slow movement and response. Tonus on
his four limbs increased and he feels asthenia from head to foot. He has
dizziness and dreamful sleep. The diagnosis for the patient was Parkinson¡¯s
disease in his country.
Diagnostic differentiation:
Differentiated with Qizong (tugging and slackening): Qizong is also called
clonic spasm. Usually, it was seen in acute fever or some chronic diseases acute
attack.
Mostly the
patients twitched continually, sometimes it accompanied by a short-term
interval. Hands and feet bending and stretching are in turn of tracing and
slacking. Some of the patients could have fever, two eyes looking upward or
clouded spirit symptoms. Trembling syndrome is a kind of chronic disease
procedure. The main symptoms present on the head, neck or four limbs
autonomously tremble or sharking. The trembling of the hands and feet has a
small extent, but a quick frequent. There are no limbs twitching traction, fever
or clouded spirit symptoms, etc. After combined analyst with his disease
history, it was not hard to distinguish them from each other.
Western medicine differential diagnosis should be differentiated from
progressive supranuclear paralysis.
Progressive
supranuclear paralysis is also often onset during the middle or odd aged people.
The clinical symptoms have extrapyramidal symptoms, such as myotonia, tremble,
etc. But this disease has a prominent obstacle on eyeballs staring. Myotonia is
mainly on the trunk of the body. Because the limb muscles are less troubled, it
keeps a good flexibility of the limb movement. The tension of neck extensor
muscle increased lead to neck hyperextension and this is different from neck
stretching of Parkinson¡¯s disease. It should be differentiated in clinical
examination.
First
diagnosis:
TCM diagnosis:
Trembling and numbness.
Symptom diagnosis:
Insufficiency
of the liver and kidney; liver wind enters the network vessels.
WM
diagnosis:
Parkinson¡¯s
disease.
Treatment strategy and daily care
1. On routine
care of traditional Chinese internal medicine
2. On grade II
care
3. Regular
diet
4. Herbal tea:
enrich the liver and kidney, extinguish wind and quicken the network vessels.
The prescription is to enrich yin and extinguish wind decoction. Such as Shoudi
(cooked rehmannia), Guiban (tortoise plastron), Tianma (gastrodia root). One
dosage a day and drink by twice, five days.
5. Massage:
once a day
6.
Acupuncture: once a day
7. Have more
medical examinations if necessary
8. Have a
positive and optimistic attitude towards the disease
Dr. Yan
Zaoming/ Dr. Dai Lei
Date:
26th of February 2007
Time: 9:00 a.m.
This morning is
Deputy Chief Physician Yan Zaoming¡¯s ward-round. The patient complained that he
has obviously whole body trembling and feels asthenia from head to foot.
He gets starting difficult, slow movement and response. He has dizziness and
dreamful sleep. Physical examination: T: 36.5¡æ£¬P:
78bpm, R: 20bpm, BP: 115/75mmHg, heart and lung (¡ª), Abdomen is flat and soft
(¡ª).
Dr. Yan¡¯s analysis:
1. The patient
has suffered from whole body trembling about 11 years accompanied by an
aggravated acratia for one year.
2. Physical
examination seen the upward recordings.
3. The patient
got the definite diagnosis in a local hospital (not in detail) was Parkinson¡¯s
disease.
Based on the
upward materials, we considered it is ¡°Tremor& paralysis¡± in TCM diagnosis.
¡°Tremor& paralysis¡± is also called ¡°Parkinson¡¯s disease¡±. This kind of disease
usually onset the middle aged or elder aged men. The characters which show in
clinical practice are trembling, tonus and reducing movement. Liver-kidney yin
depletion is the main pathogenesis of this disease. The old people mostly have
blood vacuity and essence depletion, and plus they do not absorb enough
nutrition, or damaged by disease, lead to liver-kidney yin depletion, and sinew
and vessels deprived of nourishment. Because it can not control liver yang, and
liver wind stirring internally, it lead to tremble or hypertonicity rigidity.
The differentiation of symptoms and signs is: insufficiency of the liver and
kidney, liver wind enter vessel.
The principle of treatment:
Enrich the
liver and kidney, extinguish wind and quicken the network vessels. The
prescription is to enrich yin and extinguish wind decoction. Such as Shoudi
(cooked rehmannia), Guiban (tortoise plastron), Tianma (gastrodia root). One
dosage a day and drink by twice, five days.
Massage and
Acupuncture: once a day. Have more medical examinations if necessary
Dr. Yan
Zaoming/ Dr. Dai Lei
Date:
27th of February 2007
Time: 9:00 a.m.
Today the patient
still complained that he has obviously whole body trembling and feels asthenia
from head to foot. He gets starting difficult, slow movement and response. He
has dizziness and dreamful sleep. Physical examination: Heart and lung (¡ª),
Abdomen is flat and soft (¡ª). He has no other special discomfort. He presented
with a bad spirit. His appetite is good. His bowel movement and urination are
normal. Red tongue, white and thin tongue fur, deep and fine pulse. The doctor
asked him to do active movement often, to take more vegetables and fruits, and
to avoid irritation food. Observe the patient¡¯s condition. Continue using the
same prescription.
Dr. Yan
Zaoming/ Dr. Dai Lei
Date:
28th of February 2007
Time: 9:00 a.m.
Today the patient
said he feels less asthenia from head to foot and whole body trembling. He still
gets starting difficult and still slowing in movement and response. There is no
dizziness on him and he had a good sleep.
Physical
examination: Heart and lung (¡ª), Abdomen is flat and soft (¡ª). He presented with
a good spirit. His appetite is good.
His bowel
movement and urination are normal. Light red tongue, white and thin tongue fur,
deep and fine pulse. The doctor asked him to build up his confident and continue
to do exercise. Observe the changes of the patient¡¯s condition. Continue using
the same prescription.
Dr. Yan
Zaoming/ Dr. Dai Lei
Date:
4th of March 2007
Time: 9:00 a.m.
Today the patient
said he feels much less asthenia from head to foot and whole body trembling. He
gets less starting difficult. He is a little less in slow movement and response.
Dizziness and dreamful sleep are nearly disappeared. Physical examination: Heart
and lung (¡ª), Abdomen is flat and soft (¡ª). He presented with a good spirit. His
appetite is good.
His
bowel movement and urination are normal. Light red tongue, white and thin tongue
fur, deep and fine pulse. The doctor asked him to cooperate with the treatment
in order to get a much better therapeutic effectiveness. Continue using the same
prescription. Such as Shoudi (cooked rehmannia), Guiban (tortoise plastron),
Tianma (gastrodia root). One dosage a day and drink by twice, five days.
Dr. Yan
Zaoming/ Dr. Dai Lei
Date:
8th of March 2007
Time: 9:00 a.m.
Today the patient
said he feels obvious less asthenia from head to foot and whole body trembling.
He gets obvious less starting difficult and less in slow movement and response.
No aversion to cold, fever, headache, dizziness, nausea, or vomit. He presents
with a good spirit. His sleep is good. His bowel movement and urination are
normal. Physical examination: Heart and lung (¡ª), Abdomen is flat and soft (¡ª).
Light red tongue, white and thin tongue fur, deep and fine pulse. Continue using
the same prescription. Observe the changes of the patient¡¯s condition.
Dr. Yan
Zaoming/ Dr. Dai Lei
Date:
12th of March 2007
Time: 9:00 a.m.
Today the patient
said he feels obvious less asthenia from head to foot and whole body trembling.
He gets obvious less starting difficult and less in slow movement and response.
Physical examination: Heart and lung (¡ª), Abdomen is flat and soft (¡ª). He
presents with a good spirit. His sleep is good. His bowel movement and urination
are normal. Continue using the same prescription. Such as Shoudi (cooked
rehmannia), Guiban (tortoise plastron), Tianma (gastrodia root). One dosage a
day and drink by twice, four days.
Light red tongue,
white and thin tongue fur, deep and fine pulse.
Dr. Yan
Zaoming/ Dr. Dai Lei
Date:
16th of March 2007
Time: 9:00 a.m.
Today the patient
said he feels obvious less asthenia from head to foot and whole body trembling.
He gets obvious less starting difficult and less in slow movement and response.
No aversion to cold, fever, headache, dizziness, nausea, or vomit. He presents
with a good spirit. His sleep is good. His bowel movement and urination are
normal. Physical examination: Heart and lung (¡ª), Abdomen is flat and soft (¡ª).
Light red tongue, white and thin tongue fur, deep and fine pulse. The patient is
going to leave the hospital today.
Dr.
Yan Zaoming/ Dr. Dai Lei
