Records of Hospitalization
Name: Fathia
Sex: Female
Age:
54
Profession: Civil servant
Nationality:
Sudan
Marital status: Married
Onset Season:
Summer Date of Admission:
May. 13th 2007
Complainer:
The patient¡¯s husband Reliability: Reliable
Major complaint:
The patient has suffered from weakness and numbness of the lower limbs for 8
years and has aggravated for 2 years.
Present illness:
In late April of 1999, the patient began to feel weakness and numbness 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 slowly. In 2001, the patient¡¯s sister was diagnosed with MS. Then the
patient went to the local government hospital for examination, too. After the
examination of MRI, the patient was diagnosed with 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 13th
2007. Since
she got the disease, her spirit, appetite, and her sleep were all poor.
Her bowel movement is
constipated,
and her urination is incontinent and frequent.
Disease history:
No history of typhoid, tuberculosis, hepatitis, malaria
or other infectious disease.
No allergic history of medicine or food. No operation or
trauma
history. No history of preventive vaccination provided. She has the history of
sore throat.
Personal history:
She was born in Sudan, living in a dry environment. No contact history of
schistosomiasis. No addiction to smoking, alcohol or special food. He was
mild-tempered and open-minded.
Marital history:
She married at 21. She had given birth to three sons and two daughters. Her
husband and children have been healthy all the time.
Menstrual history:
Her menstrual started at the 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 bpm, R 20bpm, BP 110/80mmHg, W 71.5kg
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. 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 78/min. Cardiac rhythm was regular. No
pathological murmurs on auscultation.
Abdomen touched flat and soft without tenderness or rebound tenderness. Liver
and spleen were not palpable. No percussion pain 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, numbness and rigiditas. Her muscle strength was Grade
¢ó
with muscle tension hyperthyroidism. The patient had difficulty in walking. Her
physiological reflex has not been elicited. Her tongue was red and purple with
tooth-marks on the edges of the tongue. The tongue coating is thick and
slightly yellow. There was spicule in the tongue root. Her pulse was fine,
rapid and week.
Diagnostic
examination: Not provided.
First diagnosis:
TCM diagnosis:
Wei-syndrome
(flaccidity syndrome)
Symptom diagnosis:
Defiency of the spleen and kidney, accompanied with moist heat.
WM diagnosis:
Multiple sclerosis
(MS)
First Medical Record
May 13th 2007
Fathia, a 54-year-old
female, has suffered from weakness and numbness of the lower limbs for 8 years
and has aggravated for 2 years. She was picked up by our staff in Huaihua
railway station and arrived in Huaihua Red Cross Hospital for further treatment
at 13: 00p.m on May 13th 2007.
Essentials for
diagnosis:
1. The patient has
suffered from weakness and numbness of the lower limbs for 8 years and has
aggravated for 2 years.
2. In the late April
of 1999, the patient began to feel weakness and numbness of the 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 with MS. Then the patient went to the
local hospital for examination, too. After the examination of MRI, the patient
was diagnosed with 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 13th
2007. Since
she got the disease, her spirit, appetite, and her sleep were all poor.
Her bowel movement was constipated, and her urination was incontinent and
frequent.
3. T 36.6¡æ£¬P
80 bpm, R 20bpm, BP 110/80mmHg, W 71.5kg
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 lower limbs were suffered from
weakness, numbness
and rigiditas. Her muscle strength was Grade
¢ó
with muscular tension hyperthyroidism. The patient had difficulty in walking.
6. No thoracic
deformity. Chest percussion noted resonance. Sound of breath is bilaterally
clear on auscultation. No sound of pleural friction.
7. Diagnostic
examination: Not provided
Diagnostic basis
TCM: The patient has
suffered from weakness and numbness of the lower limbs for 8 years and has
aggravated for 2 years. The patient was with
weakness of the
spleen and stomach, deficiency of source of qi and blood. Her essence-blood
could not nourish her organism. Therefore, she felt flaccidity of organism. She
was with the deficiency of liver and kidneys, and her essence-blood could not
nourish her sinews and vessels. Gradually it resulted in flaccidity of kidney,
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 numbness of the lower limbs for 8 years
and has aggravated for 2 years.
The lower limbs were suffered from
weakness, numbness
and rigiditas. Her muscle strength was Grade
¢ó
with muscular tension hyperthyroidism. The patient had difficulty in walking.
After the examination of MRI, the patient was diagnosed with MS in her national
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.
A 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 by 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 grave myasthenia gravis, which can occur at any
age and there are about 60 percent people stricken before 30 years old.
Women are more
often affected than men are. The most obvious characteristic of MG is rapid
fatigability of the skeletal muscles affected, improved with rest or medicines
that
inhibits the activity
of cholinesterase.
The patient¡¯s condition fluctuates, relatively better in the morning and worse
at night. The onset is all of a sudden, often begins with a group of muscles,
and as time goes on, the disease progressively affects other groups. It is most
common that the cranial innervate muscles are often the first group of muscles
to be affected evidenced by the fact that about 90 percent of persons with MG
have such initial symptoms as drooping eyelids (ptosis) and double vision (diplopia).
In addition, the bulbar muscles and girdle muscles are often the second group of
muscles to be affected. MG patients of different ages often have different
clinical manifestations and courses, which are different from those of Wei-syndrome
patients.
First diagnosis:
TCM diagnosis:
Wei-zheng (flaccidity syndrome)
Symptom diagnosis:
Deficiency of
the spleen and kidney, accompanied with moist heat.
WM diagnosis: MS
Plan for treatment
strategy and nursing
1. On routine care of
traditional Chinese internal medicine
2. On grade II care
3. Under care of a
companion
4. Low-protein diet
5. Herbal tea (to
fortify the spleen and to tonify the kidney,
to resolve heat
and to disinhibit dampness): one dosage a day and drink by twice
Prescription:
Variable in
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 14th
2007 Time: 9:00 a.m.
The patient¡¯s husband
complained to Dr. Zhang that the patient has suffered from weakness and numbness
of the lower limbs for 8 years and has aggravated for 2 years.
The patient¡¯s lower limbs were suffered
from weakness, numbness 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. Her tongue was red
and purple with tooth-marks on the edges of the tongue. The tongue coating is
thick and slightly yellow. There was spicule in the tongue root. Her pulse
was fine, rapid and week.
She was
with the history of
frequent sore throat. (The patient¡¯s sister had suffered MS and had been dead
for two years.) After the diagnosis of TCM, the patient was suffered from
flaccidity syndrome, which belonged to
depletion and vacuity
of the spleen and kidney, accompanied with moist heat.
The patient should fortify the spleen and supplement the kidney,
resolve heat
and disinhibit dampness. Doctor¡¯s requirement: take three dosages of herbal tea
of the same prescription. One dosage a day and drink by twice
Date: May 15th
2007 Time: 10:00 a.m.
The patient did not
complain about any other special discomfort and still felt
her lower limbs
weakness, numbness
and rigiditas. She still had difficulty in walking.
The examination to the function of her liver and kidney was normal, and ESR was
18mm/n(+). Her sleep and diet were still poor. Her bowel movement and urination
are normal. Doctor¡¯s requirement: let the patient build confidence and keep an
open-minded moon. The herbal tea should follow the original formulation.
Date: May 17th
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 urination
and urinary incontinence.
After the examination of her urine, her
OB (occult blood) +2.
After the examination of microscope, her MBC was 3 to 8/HP, and her RBC was 2 to
5/ HP. It was considered as urethral canal infection.
Date: May 21st
2007 Time: 9:00 a.m.
Today the patient¡¯s
appetite was normal. Her sleep was not very good.
She was with frequent
and urgent urination. Her UPD was small. After the analysis of urine and the
examination of microscope, her RBC 5 to 8/HP.
her
OB (occult blood) +2.
There was some urine in bladder after the examination of B-ultrasomotonography.
The patient had urinary incontinence and urethral canal infection. Therefore,
she needs 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 and urgent
urination and urinary incontinence were not stable. Her ankle-joints were still
stiff. Her lower limbs were still suffered
from weakness and numbness. She could walk slowly and still forgetful.
Date: May 26th
2007 Time: 9:00 a.m.
The patient¡¯s
frequent and urgent
urination 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) +2. After the examination of microscope, her MBC (+), and her RBC
was 2 to 5/ HP. There is no obvious improvement.
Doctor¡¯s requirement:
take three dosages of herbal tea of the same prescription.
Date: May 29th
2007 Time: 9:00 a.m.
The patient¡¯s
frequent and urgent
urination got further improvement. Last night, she had only twice urination,
without enuresis. Her difficulty in walking also got some improvement.
Doctor¡¯s requirement: take four dosages of herbal tea of the same prescription.
Date: June 2nd
2007 Time: 9:00 a.m.
The patient¡¯s
urinary frequency and
urgency 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:
take four dosages of 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 6th
2007 Time: 9:00 a.m.
The patient health
condition got further improvement. Doctor¡¯s requirement: take four dosages of
herbal tea of the same prescription.
Date: June 7th
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 10th
2007 Time: 9:00 a.m.
The patient¡¯s
urinary frequency and
urgency 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,
numbness and rigiditas of her double limbs disappeared. She could take big
steps.
Doctor¡¯s requirement: take four dosages of herbal tea of the same prescription.
Date: June 14th
2007 Time: 9:00 a.m.
After the treatment
of herbal tea, acupuncture and massage in our hospital, the weakness, numbness
and rigiditas of the patient¡¯s limbs were becoming better gradually. She had
totally regained so far. She could walk normally.
Her
frequent and urgent
urination 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 herbal tea
of the same prescription home for further treatment.
