Brief Summary: Fathia, from Sudan, has suffered from weakness and
numbness of the lower limbs for 8 years. After one-month
treatment in our hospital, her condition has been
improved a lot.
Record of
Hospitalization
Name:
Fathia Sex: Female
Age:
54
Profession: Civil servant
Nationality:
Denmark
Marital Status: Married
Onset Season:
Summer
Date of Admission: May. 13, 2007
Complainer:
The patient¡¯s
husband Reliability: Reliable
Major Complaint:
The patient has suffered from weakness and anaesthesia of the double lower limbs
for 8 years, and her condition has been aggravated for 2 years.
Present Illness:
In late
April 1999, the patient began to feel weakness and anaesthesia of the double
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 slowly. In 2001, the patient¡¯s sister was diagnosed as MS. Then the
patient went to the local government hospital for examination, too. After the
examination of MRI, the patient was diagnosed as MS. After that, she has been
taking
Prednisolone,
azathioprine,
amantadine
and Vietnam E until now. However, her disease had no obvious improvement. In
2005, her condition was aggravated.
She had difficulty in walking accompanied by hypomnesia. She still took no other
treatment. She
came to our hospital for further treatment on
May 13,
2007. Since she
got the disease, her spirit, her appetite, and her sleep were all poor.
Her bowel movement was
dry and hard,
and her urination was incontinent and frequent.
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. With the history of sore
throat.
Personal History:
She was
born in Denmark, living in a dry environment. No contact history of
schistosomiasis. No addiction to smoking, alcohol or special food. She was
even-tempered and open-minded.
Marital History:
She got
married at the age of 21. She has given birth to three sons and two daughters.
Her husband and children have been healthy all the time.
Menstrual History:
Her
menstrual onset was at her age of 15. Generally, her
menstrual period was
three to five days every 28 to 30 days. Her menelipsis was in 2003.
Family History:
Her
parents were both healthy. No family history of special disease. The patient¡¯s
sister suffered MS and died in 2005. The patient herself complained the disease
history, so it was reliable.
Physical Examination:
T 36.6¡æ£¬P
80 beats/minute, R 20 times/minute, BP 110/80 mmHg, W 71.5 kg.
She grew
normally with common nourishment. 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 78 times/minute. Cardiac rhythm
was regular. No pathological murmurs on
auscultation. Abdomen touched flat and soft without tenderness or rebounding
tenderness. The liver and spleen were not palpable. No percussion pains in renal
region. Bowel sound was normal. No spinal and pelvic deformity or tenderness. No
deformity or inflexibility of the double upper limbs. The double lower limbs
were suffered from weakness, anaesthesia and rigiditas. Her muscle
strength was Grade
¢ó
with muscle tension hypertonicity. The patient had difficulty in walking. Other
physiological reflex has not been elicited. Her tongue was red and purple with
yellow and deep tongue coating. There were dental impressions in the margins of
the tongue, and there was spicule in the tongue root. Her pulse was thin and
week.
Diagnostic
examination: Not provided.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification:
Depletion and vacuity of the spleen and kidneys, accompanied by moist heat.
Western medicine
diagnosis:
Multiple sclerosis (MS)
First Medical Record
May 13,
2007
Fathia, a 54-year-old
female, has suffered from weakness and anaesthesia of the double lower limbs for
8 years, and her condition has been aggravated for 2 years. She was picked up by
our workers in Huaihua railway station and arrived in Huaihua Red Cross Hospital
for further treatment at 13: 00 p.m. on May 13, 2007.
Essentials for
Diagnosis:
1. The patient has
suffered from weakness and anaesthesia of the double lower limbs for 8 years,
and her condition has been aggravated for 2 years.
2. In the late April
1999, the patient began to feel weakness and anaesthesia of the double lower
limbs without any obvious cause. At that time, the patient paid no attention to
it, and did no treatment about it. Therefore, the disease was developing slowly.
In 2001, the patient¡¯s sister was diagnosed as MS. Then the patient went to the
local hospital for examination, too. After the examination of MRI, the patient
was diagnosed as MS. After that, she has been taking
hydrogenated
nm, azathioprine,
decane amine
tricyclic and Vietnam E until now. However, her disease had no obvious
improvement. In 2005,
her condition was aggravated.
She had difficulty in walking accompanied by hypomnesia. She still took no other
treatment. She
came to our hospital for further treatment on
May 13, 2007.
Since she got the
disease, her spirit, her appetite, and her sleep were all poor.
Her bowel movement was dry and hard, and her urination was incontinent and
frequent.
3. T 36.6¡æ£¬P
80 beats/minute, R 20 times/minute, BP 110/80 mmHg, W 71.5 kg.
4. She grew normally
with common nourishment. 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.
5.
The double lower limbs were suffered
from weakness,
anaesthesia and rigiditas. Her muscle strength was Grade
¢ó with muscle tension hypertonicity. The patient had
difficulty in walking.
6. No thoracic
deformity. Chest percussion noted resonance. Sound of breath was bilaterally
clear on auscultation. No sound of pleural friction.
7. Diagnostic
examination: Not provided.
Diagnostic Basis:
TCM: The patient has
suffered from weakness and anaesthesia of the double lower limbs for 8 years,
and her condition has been aggravated for 2 years. Due to the
weakness of the spleen and stomach, deficiency of source of
the qi and blood, her essence-blood could not nourish her organism. Therefore,
she felt flaccidity of organism. Due to the depletion and vacuity of the liver
and kidneys, her essence-blood could not nourish her sinews and vessels.
Gradually it resulted in flaccidity of kidneys, deficiency of marrow, weakness
of lower limbs and thin pulse. These are also the reflections of depletion and
vacuity of yin and blood.
Western medicine: The
patient has suffered from weakness and anaesthesia of the double lower limbs for
8 years, and her condition has been aggravated for 2 years.
The double lower limbs were suffered from
weakness,
anaesthesia and rigiditas. Her muscle strength was Grade
¢ó with muscle tension hypertonicity. The patient had
difficulty in walking.
After the examination of MRI, the patient was diagnosed as MS in her national
hospital.
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 attracted, though he or she usually has no joint pains. On the
contrary, impediment syndrome is generally characterized as aching pains, 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.
Western medicine:
Wilting syndrome should be differentiated from myasthenia gravis, which can
occur at any age and there are about 60 percent people stricken before 30 years
old. Myasthenia gravis is a kind of
autoimmune disease that there appear transmitting obstacles in
the
site of neuromuscular junction
owing to the reduced
acetylcholine receptor. Women are more often affected than men are. The most
obvious characteristic of MG is rapid fatigability and weakness of the
striated
muscles part of the
body or all over the body affected. It will be improved with rest or medicines
that
inhibit the activity of cholinesterase.
It can also involve
cardiac muscle and
smooth muscle.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification:
Depletion and vacuity of the spleen and kidneys, accompanied by moist heat.
Western medicine
diagnosis: MS
Plans for treatment
strategy and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade II care.
3. Under care of a
companion.
4. Low-protein diet.
5. Herbal tea (to
fortify the spleen and supplement the kidneys,
resolve heat
and disinhibit dampness): one dosage a day and drink twice.
Prescription: Varied formula of the Four Gentlemen Decoction and Mysterious Four
Powders.
Main herbs used in
the herbal tea: huangqi (astragalus root), dangshen (codonopsis root), fuling (poria),
etc.
6. Acupuncture and
massage: once a day.
7. Have more medical
examinations if necessary.
Date: May 14,
2007 Time: 9:00 a.m.
The patient¡¯s husband
complained to Dr. Zhang that the patient has suffered from weakness and
anaesthesia of the double lower limbs for years, and her condition has been
aggravated for 2 years.
The patient¡¯s double lower limbs were suffered from
weakness, anaesthesia
and rigiditas. She had difficulty in walking. She had lumbar myalgia with
amnesia. Her
urination is incontinent and frequent. She was with feet fever, poor sleep and
diet. Her mouth was dry.
She is with red and purple tongue, yellow and deep
tongue coating. There is indentation in the edges of the tongue, and there is
spicule in the ball of the tongue. Her pulse is thin and week. She had
the history of frequent sore throat. (The patient¡¯s sister had suffered MS and
had been dead for two yeas.) After the diagnosis of TCM, the patient was
suffered from flaccidity syndrome, which belonged to
depletion and vacuity of
the spleen and kidneys, accompanied with moist heat.
The patient should fortify the spleen and supplement the kidneys, resolve heat
and disinhibit dampness.
Doctor¡¯s requirement is to take three dosages of the herbal tea of the same
prescription. One dosage a day and drink twice
Date: May 15,
2007 Time: 10:00 a.m.
The
patient did not complain about any other special discomfort and still felt
her double lower limbs
weakness, anaesthesia
and rigiditas. She still had difficulty in walking.
The examination of the function of her liver and kidneys was normal, and ESR was
18mm/n (+). Her sleep and diet were still poor. Her bowel movement and urination
are normal. Doctor¡¯s requirement is to let the patient build confidence and keep
an open-minded moon. The herbal tea should follow the
original formula.
Date: May 17,
2007 Time: 9:00 a.m.
Since the patient
taking our herbal tea in our hospital, her appetite has increased gradually. Her
sleep was still poor. She still had
frequent micturition and urinary
incontinence.
After the examination of her urine, her
OB (occult blood) was
+2. After the examination of microscope, her MBC showed 3 to 8/HP, and her RBC
was 2 to 5/ HP. It was considered as urethral canal infection.
Date: May 21,
2007 Time: 9:00 a.m.
Today the patient¡¯s
appetite was normal. Her sleep was not very good.
She had frequent micturition and
urgent micturition. Her UPD was small. After the
analysis of urine and the examination of microscope, her RBC showed 5 to 8/HP.
her
OB (occult blood)
+2. There was some urine in bladder after the examination of B-ultrasonic. The
patient had urinary incontinence and urethral canal infection. Therefore, she
need use sanitary towel.
Date: May 23rd
2007 Time: 9:00 a.m.
Today the patient¡¯s
appetite was normal. Her sleep was not very good. Her
frequent micturition, urgent
micturition and urinary incontinence were not stable. Her
ankle-joint was still
spastic. Her
double lower limbs were still suffered from
weakness and anaesthesia. She could walk slowly and still forgetful.
Date: May 26,
2007 Time: 9:00 a.m.
The patient¡¯s
frequent micturition and urgent micturition got some improvement. She had three
times urination on average in the daytime and at night. Her difficulty in
walking also got some improvement. The patient¡¯s mood was rather pleasant. After
the examination of her urine, her
OB (occult blood)
showed +2. After the examination of microscope, her MBC (+), and her RBC was 2
to 5/ HP. There is no obvious improvement.
Doctor¡¯s requirement is to take
three dosages of the herbal tea of the same prescription.
Date: May 29,
2007 Time: 9:00 a.m.
The patient¡¯s
frequent micturition and urgent
micturition got further improvement. Last night, she had only twice urination,
without enuresis. Her difficulty in walking
also got some improvement.
Doctor¡¯s requirement is to take four dosages of the herbal tea of the same
prescription.
Date: June 2,
2007 Time: 9:00 a.m.
The patient¡¯s
frequent micturition and urgent
micturition got obvious improvement.
She had no
urinary incontinence. Her weak lower
limbs and her difficulty in walking got further improvement. Her sleep was still
not very good. Sometimes she felt dizzy and forgetful. The patient asked for
strengthening her memory.
Doctor¡¯s requirement is to take four dosages of the herbal tea of the same
prescription. The prescription should increase acorus root by 5 grams, spiny
jujube kernel by 5 grams and polygala root by 5 grams.
Date: June 6,
2007 Time: 9:00 a.m.
The patient health
condition got further improvement.
Doctor¡¯s requirement is to take
four dosages of the herbal tea of the same prescription.
Date: June 7,
2007 Time: 9:00 a.m.
Today the patient¡¯
husband told the doctor that the patient health was becoming better. Her mood
was very pleasant. The patient still wanted to stay for another month¡¯s
treatment, but her family condition disallowed her.
Date: June 10,
2007 Time: 9:00 a.m.
The patient¡¯s
frequent micturition and urgent
micturition almost disappeared. Last night, she only had once urination. She had
no feelings of urinary incontinence these days. Her sleep and her memory were
becoming better. The patient was in a positive mood. The symptoms of weakness,
anaesthesia and rigiditas of her double limbs
disappeared. She could take big steps.
Doctor¡¯s requirement is to take
four dosages of the herbal tea of the same prescription.
Date: June 14,
2007 Time: 9:00 a.m.
After
our treatment of herbal tea, acupuncture and massage in our hospital, the
weakness, anaesthesia and rigiditas of the
patient¡¯s double limbs were becoming better gradually. She has regained her
health completely so far. She could walk normally.
Her
frequent micturition, urgent micturition and urinary incontinence disappeared.
Her urination was normal. The symptoms of forgetfulness and insomnia got obvious
improvement. The patient was in a very positive mood. The patient demanded to
leave the hospital today. Besides, she would like to take 60 dosages of the
herbal tea of the same prescription home for further treatment.
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