Records of
Hospitalization
Name: Audra
Sex: Female
Age: 50
Profession: Surgeon
Nationality:
Lithuania
Marital status: Married
Onset Season:
Spring Date of Admission:
April 28th 2007
Complainer: The
patient¡¯s herself Reliability:
Reliable
Major complaint:
The patient has suffered from muscular
rigidity and weakness
of her lower limbs and from walking unsteadily for 5 years, aggregately
accompanied by disability of walking for half a year.
Present illness:
In 2002, the patient began to feel muscular
rigidity and weakness
of the lower limbs 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 numbness of her lower limbs. She began to use wheelchair. Then she started
to take our herbal tea prescribed from our hospital until now, and the numbness
of her lower limbs disappeared.
She came to our
hospital for further treatment on
April 28th
2007. Since
she got the disease, her spirit, appetite, and her sleep were all normal.
The bowel
movement and urination were both 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 disease. 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 mild-tempered and open-minded.
Marital history: She
married at 23 years old. She had given birth to a daughter. Her husband and her
daughter have been healthy all the time.
Menstrual history:
Her menstruation started at the age of 14. Generally her
menstrual period
lasted 3 to 5 days every 28 to 30 days. Her menelipsis was on March 27th
2003.
Family history: Her
parents are both healthy. No family history of special disease.
Physical examination
T 36.4¡æ£¬P
80 bpm, R 21bpm, BP 110/80mmHg, K: 65kg
She is mid-nourished and
normally developed. Her mind is clear. She has an expression of chronic illness
and languidness. She is in a positive position and cooperative in examination.
Her 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 normal. Heart beat
80 times/min. Heart rhythm is regular. No pathological murmurs on
auscultation. Abdomen touches flat and soft
without tenderness or rebound tenderness. Liver and spleen are not checked. No
percussion pains in renal region. Bowel sound is normal. No spinal and pelvic
deformity or tenderness. No deformity or inflexibility of the upper limbs. The
muscular rigidity and weakness of the
lower limbs. Her ankle-joints and
knee joints are spastic with difficulty in movement. Her lower limbs are
obviously weak. Her muscle strength is Grade
¢ò with muscle tension
hyperthyroidism. Her anus and pudendum are normal. Her physiological reflex has
not been elicited. Her tongue is dull with thin and white tongue coating. The
right pulse is stringy-like and slippery. The left pulse is week.
Diagnostic
examination: Not provided.
First diagnosis:
TCM diagnosis:
Membra rigidity
(flaccidity syndrome)
Symptom diagnosis:
deficiency of the liver and kidneys, and liver wind entering the network
vessels.
WM diagnosis: 1.Multiple
sclerosis (MS)
2. Multiple obsolete
cerebral infarctions
First Medical Record
April 28th 2007
Audra, a 50-year-old
female, has suffered from muscular
rigidity and weakness
of her lower limbs and from walking unsteadily for 5 years, aggregately
accompanied by walking disability for half a year. She was picked up by our
staff in Zhijiang Airport and arrived at Huaihua Red Cross Hospital for further
treatment at 14: 00p.m on April 28th 2007.
Symptoms of the
disease:
1. The patient has
suffered from muscular
rigidity and weakness
of her lower limbs and from walking unsteadily for 5 years, aggregately
accompanied by disability of walking for half a year.
2. In 2002, the
patient began to feel muscular
rigidity and weakness
of the lower limbs 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 with 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 numb of her lower limbs. She began to use wheelchair. Then she began to
take our herbal tea prescribe from our hospital until now, and the numbness of
her lower limbs disappeared.
She came to our
hospital for further treatment on
April 28th
2007. Since
she got the disease, her spirit, appetite, and her sleep were all normal.
Her bowel
movement and urination were normal.
3. T 36.4¡æ£¬P
80 bpm, R 21bpm, BP 110/80mmHg, K: 65kg
4. She was
mid-nourished and normally developed. Her mind was clear. She had an expression
of chronic illness and languidness. She was in a positive position and
cooperative in examination.
5.
The muscular
rigidity and weakness of her lower limbs.
Her ankle-joints and knee joints are spastic with difficulty in movement. Her
lower limbs are obviously weak. Her muscle strength is Grade
¢ò with muscle tension
hyperthyroidism.
6. No thoracic
deformity. Clear percussion sound. Sound of the lungs breath is bilaterally
clear on auscultation. No sound of pleural friction.
7. Diagnostic
examination: Not provided
Diagnosis:
TCM: The patient has
suffered from muscular
rigidity and weakness
of her lower limbs and from walking unsteadily for 5 years, aggregately
accompanied by unable to walk for half a year. The patient was with
deficiency of the liver and kidney. The essence-blood could not nourish her
sinews and vessels. Gradually it formed flaccidity syndrome. The Wei-syndrome
resulted in depletion of essence and blood, malnutrition of channel sinew,
deficiency of marrow and limp aching lumbus and knees.
Western medicine:
The lower limbs got muscular
rigidity and
weakness. Her ankle-joint and knee joints were spastic with difficulty in
movement. Her lower limbs were obviously weak. Her muscle strength was Grade
¢ò with muscle tension
hyperthyroidism.
After the examination
of MRI, the patient was diagnosed with MS in the local government hospital.
Diagnostic
differentiation
TCM: The patient¡¯s
Wei-syndrome should be differentiated from Bi-syndrome. Wei-syndrome is
characterized by limp, weak, and emaciated limbs with
muscular atrophy.
The patient suffered from Wei-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 pain. On the contrary,
Bi-syndrome is generally characterized as aching pain, 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.
WM: Wei-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
cerebral vascular accident, cerebral ischemia or by oppressing and moving of
hematoma, cerebral edema, which destroy the function of the brain tissue. 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
(flaccidity syndrome).
Symptom diagnosis:
Deficiency of
the liver and kidney, and liver wind entering the network vessels.
WM diagnosis: 1.
Multiple sclerosis (MS).
2. Multiple obsolete
cerebral infarctions
Plan 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. Pleasant diet
5. Herbal tea (to
fortify and nourish the liver and kidney, to extinguish wind and free the
network vessels.) one dosage a day and drink by twice.)
Prescription:
Variable in 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 29th
2007 Time: 9:00 a.m.
Today the patient
complained to Dr. Yang about the muscular
rigidity and
weakness of her lower limbs. She was unable to walk.
The examination to
the function of her liver and kidney was normal, and the examination to BS, and
electrolyte
blood-fat were all-normal.
Examination: T 36.4¡æ£¬P
80 bpm, R 21bpm, BP 110/80mmHg, K: 65kg.
His heart and lung
were normal, and his 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,
aggregately accompanied by unable to walk for half a year.
2.
The lower limbs¡¯ muscular were suffered from
rigidity and
weakness. Her ankle-joint and knee joints were spastic with difficulty in
movement. Her lower limbs were obviously weak. Her muscle strength was Grade
¢ò
with muscle
tension hyperthyroidism.
3.
After the examination
of MRI, the patient was diagnosed with MS in her national hospital. Wei-syndrome
is characterized as limp, weak, and emaciated limbs with
muscular atrophy.
The patient could not move freely. The patient was with
deficiency of the
liver and kidney. Her essence-blood could not nourish her sinews and vessels.
Gradually it formed flaccidity syndrome. The Wei-syndrome resulted in depletion
of essence and blood, malnutrition of channel sinew, deficiency of marrow and
limp aching lumbus and knees.
Doctor¡¯s diagnosis:
Deficiency of
the liver and kidney, and liver wind entering the network vessels.
Doctor¡¯s strategy: fortify and tonify the liver and kidney, extinguish wind and
free the network vessels.
Doctor¡¯s requirement:
take two dosages of herbal tea of the same prescription. One dosage a day and
drink by twice. Acupuncture and massage practiced once a day. The patient should
have more medical examinations if necessary.
Date: April 30th
2007 Time: 14:00 a.m.
The patient did not
complain about any other special discomfort and still complained about the
muscular rigidity and weakness of
her lower limbs, and she was still unable to walk.
Today, she had a MRI examination to 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 exists multiple obsolete
cerebral infarct on her right occipital lobe and bilateral centrum semiovale. 3.
Degeneration of cervical vertebra. 4. C4/5, C5/6 protrusion of ntervertebral
disc. 5. Degeneration and atrophy of 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 tonify the liver and
kidney, to extinguish wind and free the network vessels, accompanied by the
treatment of acupuncture and massage.
Date: May 1st
2007 Time: 9:00 a.m.
The patient did not
complain that she had muscular rigidity and weakness of the
lower limbs, and she was still
unable to walk. His heart and lung were normal, and her abdomen was soft and
flat. The examination to her lower limbs was the same as before. Her spirit,
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 stringy-like and slippery. The left pulse was week. Doctor¡¯s requirement:
take three dosages of herbal tea of the same prescription. One dosage a day and
drink twice.
Date: May 5th
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained that
she had muscular rigidity and
weakness of the lower limbs, and she was still unable to walk. Her heart and
lung were normal. The abdomen was soft and flat. The examination to her lower
limbs was the same as before. Her spirit, 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 stringy-like and slippery.
The left pulse was week. Doctor¡¯s requirement: take herbal tea of the same
prescription. One dosage a day and drink twice.
Date: May 8th
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained that
she had muscular rigidity and
weakness of the lower limbs, and she was still unable to walk. Her heart and
lung were normal, and her abdomen was soft and flat. The examination to her
lower limbs was the same as before. Her spirit, 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 stringy-like and slippery.
The left pulse was stringy-like and week. Doctor¡¯s requirement: take herbal tea
of the same prescription. One dosage a day and drink twice.
Date: May 13th
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained that
she had muscular rigidity and
weakness of the lower limbs, and she was still unable to walk. Her heart and
lung were normal, and her abdomen was soft and flat. The examination to her
lower limbs was the same as before. Her spirit, 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 stringy-like and slippery.
The left pulse was stringy-like and week. Doctor¡¯s requirement: take five
dosages of herbal tea of the same prescription. One dosage a day and drink
twice.
Date: May 18th
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained that
she had muscular rigidity and
weakness of the lower limbs, and she was still unable to walk. Her heart and
lung were normal, and her abdomen was soft and flat. The examination to her
lower limbs was the same as before. Her spirit, 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 stringy-like and slippery.
The left pulse was stringy-like and week. Doctor¡¯s requirement: take herbal tea
of the same prescription. One dosage a day and drink twice.
Date: May 22nd
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained that
she had muscular rigidity and
weakness of the lower limbs, and she was still unable to walk. Her heart and
lung were normal, and her abdomen was soft and flat. The examination to her
lower limbs was the same as before. Her spirit, 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 stringy-like and slippery.
The left pulse was stringy-like and week. Doctor¡¯s requirement: take five
dosages herbal tea of the same prescription. One dosage a day and drink twice.
Date: May 27th
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained that
she had muscular rigidity and weakness of the lower limbs, and she was
still unable to walk.
Examination: T 36.7¡æ£¬P
80 bpm, R 20bpm, BP 120/75mmHg.
Her heart and lung
were normal, and her abdomen was soft and flat. The examination to her lower
limbs was the same as before. Her spirit, 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 stringy-like and slippery.
The left pulse was stringy-like and week. Doctor¡¯s requirement: take herbal tea
of the same prescription. One dosage a day and drink twice.
Conclusion
Date: May 28th
2007 Time: 10:00 a.m.
Audra, a 50-year-old
female, has suffered from
muscular
rigidity and weakness of the lower limbs, and
walking unsteadily for 5 years, aggregately accompanied by unable to walk for
half a year. She was picked up by our staff in Zhijiang Airport, and she arrived
at Huaihua Red Cross Hospital for further treatment at 14: 00p.m on April 28th
2007.
Physical examination
T 36.4¡æ£¬P
80 bpm, R 21bpm, BP 110/80mmHg, K: 65kg
She was mid-nourished
and normally developed. Her mind was clear. She has an expression of chronic
illness and languidness. She was in a positive position and cooperative in
examination. Her heart and lung were normal, and her abdomen was soft and flat.
The lower limbs¡¯ muscular were suffered
from rigidity and weakness. Her ankle-joint and knee joints were spastic
with difficulty in movement. Her lower limbs were obviously weak. Her muscle
strength was Grade
¢ò
with muscle
tension hyperthyroidism. Her spirit, appetite and her sleep were all normal. Her
bowel movement and urination were normal.
First diagnosis:
TCM diagnosis:
Membra rigidity
(flaccidity syndrome)
Symptom diagnosis:
Deficiency of the liver and kidney, and liver wind entering the network
vessels..
WM diagnosis: Multiple
sclerosis (MS)
The process of
treatment: the patient has taken our herbal tea to
fortify and nourish the liver and kidney, to extinguish wind and free the
network vessels
since she arrived at
our hospital. The prescription:
One dosage a day and
drink by 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, appetite and her sleep were all normal. Her bowel movement and urination
were normal.
Examination: T 36.3¡æ£¬P
80 bpm, R 21bpm, BP 110/80mmHg, K: 65kg
Her heart and lung
were normal, and her abdomen was soft and flat.
The muscular rigidity and weakness
of the lower limbs. Her ankle-joint and knee joints wer spastic with difficulty
in movement. Her double lower limbs were obviously weak. Her muscle strength was
Grade
¢ò
with muscle
tension hyperthyroidism. Her tongue was light red with thin and white tongue
coating. Her pulse was slippery.
Current diagnosis:
TCM diagnosis:
Membra rigidity
(flaccidity syndrome)
Symptom diagnosis:
Deficiency of the liver and kidney, and liver wind entering the network
vessels..
WM diagnosis: Multiple
sclerosis (MS)
Plan for treatment
strategy and nursing:
1. Continue taking
herbal tea to fortify and nourish the liver and kidney, and to extinguish wind
and free the network vessels.
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 2nd
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained about the
muscular rigidity and weakness of the lower limbs, and she was still unable to
walk.
Examination: T 36.5¡æ£¬P
80 bpm, R 20bpm, BP 120/75mmHg.
Her heart and lung were
normal, and her abdomen was soft and flat. The examination to her lower limbs
was the same as before. Her spirit, 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 stringy-like and slippery. Doctor¡¯s
requirement: take herbal tea of the same prescription. One dosage a day and
drink twice.
Date: June 7th
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained about the
muscular rigidity and weakness of the lower limbs, and she was still unable to
walk.
Examination: T 36.5¡æ£¬P
80 bpm, R 20bpm, BP 120/75mmHg.
Her heart and lung were
normal, and her abdomen was soft and flat. The examination to her lower limbs
was the same as before. Her spirit, appetite and her sleep were all normal. Her
bowel movement and urination were normal. Her tongue was dull. Her pulse was
stringy-like and slippery. Doctor¡¯s requirement: take five dosages herbal tea of
the same prescription. One dosage a day and drink twice.
Date: June 12th
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained about the
muscular rigidity and weakness of the lower limbs, and she was still unable to
walk.
Examination: T 36.5¡æ£¬P
80 bpm, R 20bpm, BP 120/75mmHg.
Her heart and lung were
normal, and her abdomen was soft and flat. The examination to her lower limbs
was the same as before. Her spirit, appetite and her sleep were all normal. Her
bowel movement and urination were normal. Her tongue was dull. Her pulse was
stringy-like and slippery. Doctor¡¯s requirement: take herbal tea of the same
prescription. One dosage a day and drink twice.
Date: June 17th
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained about the
muscular rigidity and weakness of the lower limbs, and she was still unable to
walk.
Examination: T 36.5¡æ£¬P
80 bpm, R 20bpm, BP 120/75mmHg.
Her heart and lung were
normal, and her abdomen was soft and flat. The examination to her lower limbs
was the same as before. Her spirit, appetite and her sleep were all normal. Her
bowel movement and urination were normal. Her tongue was dull. Her pulse was
stringy-like and slippery. Doctor¡¯s requirement: take herbal tea of the same
prescription. One dosage a day and drink twice.
Date: June 22nd
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still complained about the
muscular rigidity and weakness of the lower limbs, and she was still unable to
walk.
Examination: T 36.5¡æ£¬P
82 bpm, R 20bpm, BP 120/75mmHg.
Her heart and lung were
normal, and her abdomen was soft and flat. The examination to her lower limbs
was the same as before. Her spirit, appetite and her sleep were all normal. Her
bowel movement and urination were normal. Her tongue was dull. Her pulse was
stringy-like and slippery. she would leave the hospital today.
