Records of Hospitalization

Name: Aafia                                          Sex: Female

Age: 4                                         Profession: None

Nationality: Pakistan                          Marital status: Unmarried

Onset Season: Spring                         Date of Admission: July 5^th 2007  

Complainer: The patient’s father

Major complaint: The patient has suffered from weakness of limbs and neck, poor activities, mental retardation, and inability to speak, accompanied by repeated convulsions for 3 years.

Present illness: when the patient was 3 months old, her parents found that the child with weakness of the head and inability to support the head. But at that time, the parents paid no attention to it, and did no treatment about it. A month later, the patient’s symptoms aggravated, accompanied by weak limbs and poor activities. Then she was diagnosed in a local hospital (unknown). After MRI examination, everything was normal. Therefore, the doctor gave her massage treatment, and the patient got some improvement. Two months later, she caught lung infection caused by cold and suffered from high fever up to 40 degrees, which led to convulsions. She was diagnosed with epilepsy in a local hospital, and was given anti- epilepsy treatment. In the following days, she was repeatedly attacked by some stimulation. Three months later, she was taken to the hospital again. After carefully examination, she was essentially diagnosed with cerebral palsy, and was given massage treatment twice a week. She was also prescribed piracetam for three times a day to increase cerebral blood flow and Phenobarbital to resist epilepsy. Her epilepsy got some improvement, but cerebral palsy got no obvious effect. The patient was not able to sit or climb. When she was 3 years old, she was still not able to speak, accompanied by poor responses to outside, mental retardation, inability to stand or recognize people. She got no other treatment besides taking the medicines of piracetam and Phenobarbital. To seek better treatment, she was picked up by our staff in Huaihua railway station to hospitalize in our hospital at 12:00 p.m. on July 5^th 2007. Since she got the disease, her spirit and appetite were both poor. Her sleep was good. Her bowel movement and urination were both incontinent.

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 blood transfusion. History of preventive vaccination not provided.

Personal history: She was born in Pakistan, in spontaneous delivery, the forth child in the family. She weighted 3.8 kg when she was born. No contact history of schistosomiasis. No bad addiction. She was mild-tempered and open-minded.

Marital history: unmarried

Family history: Her parents were both healthy. No history of special disease in her family.

T 36.6℃，P 90 bpm, R 26bpm, K:16kg  

She was poor-nourished and slowly developed. Her mind was faint. She had an expression of chronic illness and languishment. She was in a passive position and uncooperative in examination. Her skin was moist. No jaundice in the sclera. No enlargement of the superficial lymph nodes. Bilateral pupils were round and equal in size and sensitive to light. No deformity of skull and the five sense organs. No congestion in throat. No swelling of tonsil. With soft neck and trachea in the middle. No enlargement of the thyroid gland. No congestion of the jugular vein. No thoracic deformity. Chest percussion noted clearly. Sound of breath was bilaterally normal on auscultation. No pleural friction rubs. Heart border was normal. Heart beat was 80 times/min. Cardiac rhythm was regular. No pathological murmurs on auscultation. Abdomen touched flat and soft without pressure 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. Weakness of the neck. Lower muscular tension of the neck. Her neck could not erect. She was suffering from weakness of limbs and inability to hold any objects with hands. She could not turn over, sit down, climb, stand up, or walking, accompanied by poor activities and difficulty in self-movement. Her muscle strength of the limbs was Grade Ⅲ with lower muscular tension. She was suffering from mental retardation, inability to recognize people, and poor response to outside, accompanied by sluggish expression and inability to speak. Sometimes she sipped figures, accompanied by crossed hands. Clinton levy and the Pap levy were both normal. Her tongue was slightly red with thin and greasy tongue coating. Her pulse was fine and weak.

Diagnostic examination: Not provided.

First diagnosis: 

TCM diagnosis: 1. Cerebral palsy

              2. Epilepsy

              3. Gan syndrome

Symptom diagnosis: Congenital insufficiency of talent, and deficiency of the liver and kidney

WM diagnosis: 1. Cerebral palsy

              2. Epilepsy

              3. Severe malnutrition

First Medical Record

July 5^th 2007

Aafia, a 4-year-old female, has suffered from weakness of limbs and neck, poor activities, mental retardation, and inability to speak, accompanied by repeated convulsions for 3 years. She was picked up by our staff in Huaihua railway station to hospitalize in our hospital at 12:00 p.m. on July 5^th 2007.

Essentials for diagnosis:

1. The patient has suffered from weakness of limbs and neck, poor activities, mental retardation, and inability to speak, accompanied by repeated convulsions for 3 years.

2. When the patient was 3 months old, her parents found that the child with weakness of the head and inability to support the head. At that time, the parents paid no attention to it, and did no treatment about it. A month later, the patient’s symptoms aggravated, accompanied by weak limbs and poor activities. Then she was diagnosed in a local hospital (unknown). After MRI examination, everything was normal. Therefore, the doctor gave her massage treatment, and the patient got some improvement. Two months later, she caught lung infection caused by cold and suffered from high fever up to 40 degrees, which led to convulsions. She was diagnosed with epilepsy in a local hospital, and was given anti- epilepsy treatment. In the following days, she was repeatedly attacked with some stimulation. Three months later, she was taken to the hospital again. After carefully examination, she was essentially diagnosed with cerebral palsy, and was given massage treatment twice a week. She was also prescribed piracetam three times a day to increase cerebral blood flow and Phenobarbital to resist epilepsy. Her epilepsy got some improvement, but cerebral palsy got no obvious effect. The patient was not able to sit or climb. When she was 3 years old, she was still not able to speak, accompanied by poor responses to outside, inability to stand or to recognize people and mental retardation. She got no other treatment besides taking the medicines of piracetam and Phenobarbital. To seek better treatment, she was picked up by our staff in Huaihua railway station to hospitalize in our hospital at 12:00 p.m. on July 5^th 2007. Since she got the disease, her spirit and appetite were both poor. Her sleep was good. Her bowel movement and urination were both incontinent.

3. T 36.6℃，P 90 bpm, R 26bpm, K:16kg 

4. She was poor-nourished and slowly developed. Her mind was faint. She had an expression of chronic illness and languishment. She was in a passive position and uncooperative in examination.

5. The patient suffered from weakness of the neck and lower muscular tension of the neck. Her neck could not erect. She was suffering from weakness of limbs and inability to hold any objects with hands. She could not turn over, sit down, climb, stand up, or walking, accompanied by poor activities and difficulty in self-movement. Her muscle strength of the limbs was Grade Ⅲ with lower muscular tension. She was suffering from mental retardation, inability to recognize people, and poor response to outside, accompanied by sluggish expression and inability to speak. Sometimes she sipped figures, accompanied by crossed hands. Clinton levy and the Pap levy were both normal.

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 of limbs and neck, poor activities, mental retardation, and inability to speak, accompanied by repeated convulsions for 3 years. The patient’s parents are relations in marriage. The patient was 3.6 kg when she was born. Her parents were with deficiency of essence and blood, which made insufficiency of fetal origin. Due to the malnutrition of fetus, the child suffered from congenital insufficiency of talent and easily attacked by external evil. The insufficiency of essence resulted in vacuity of brains. The insufficiency of heart resulted in inability to nourish heart. The damage of the sea of medulla, insufficiency of heart and spleen, deficiency of qi and blood, stagnation of qi and sputum crudum, stasis of sputum and stagnation of vessels, brain fooled, fatigue of essence and dryness of marrow, and malnutrition of muscle and vessel all resulted in acquired malnutrition. Therefore, the essence-blood could not nourish the limbs, which led to wilting limbs and dysfunction of spasm.

Western medicine: The patient has suffered from weakness of limbs and neck, poor activities, mental retardation, and inability to speak, accompanied by repeated convulsions for 3 years. The patient suffered from weakness of the neck and lower muscular tension of the neck. Her neck could not erect. The patient was suffering from weakness of limbs and inability to hold any objects with hands. She could not turn over, sit down, climb, stand up, or walking, accompanied by poor activities and difficulty in self-movement. Her muscle strength of the limbs was Grade Ⅲ with lower muscular tension. She suffered from mental retardation, inability to recognize people, and poor response to outside, accompanied by sluggish expression and inability to speak. Sometimes she sipped figures, accompanied by crossed hands. Clinton levy and the Pap levy were both normal.

Diagnostic differentiation

TCM: it should be differentiated from loose skull. The patient with severe loose skull was with the symptoms of closed fontanesl, slow development, and blunt mind, accompanied by difficulties in raising head, unsteady steps, and epileptic attack. It is fundamentally caused by congenital defect, deficiency of qi and blood, six-excess external contraction, stagnation of meridian, and water-damp accumulated in brain. The clinical manifestations are brains enlargement, exposed blue veins, percussing with cracked-pot sound, eyeballs like sunset, tropia, headache, and vomiting. They are not difficult to be distinguished in clinics.

Western medicine: it should be differentiated from progressive muscular dystrophy, which is a hereditary disease primarily attacking muscle. Most of patients with the disease have family history. The clinical manifestations are chronic progressive aggravating symmetric myasthenia and muscle atrophy. Some individual type of the disease involves cardiac muscle. Different types attack different ages of people with different clinical manifestations and distribution of muscle disease. In short, it always attacks child and teenagers.

First diagnosis: 

TCM diagnosis: 1. Cerebral palsy

              2. Epilepsy

              3. Gan syndrome

Symptom diagnosis: Congenital insufficiency of talent, and deficiency of the liver and kidney

WM diagnosis: 1. Cerebral palsy

              2. Epilepsy

              3. Severe malnutrition

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. High protein diet

5. Herbal tea (to boost qi and fortify spleen, to nourish liver and kidneys): one dosage a day and drink twice

Prescription: Variable in sagely spleen-fortifying brain-supplementing decoction

Main herbs used in the herbal tea: Yizhiren (Alpinia fruit), Shudi (Cooked Rehmannia root), Danggui (Tangkuei), etc.

6. Acupuncture and massage: once a day

7. Have more medical examinations if necessary

Date:  July 6^th 2007                                 Time: 9:00 a.m.

Today the patient’s father complained to Dr. Yan that the patient was suffering from weakness of limbs and neck, poor activities, mental retardation, and inability to speak, accompanied by sometimes attacked by convulsions for 10 seconds to 1 minute every time. Examination: T 36.6℃，P 90 bpm, R 26bpm, K:16kg 

Her heart and lung were normal. The abdomen was soft and flat.

Dr. Yan’s analysis:

1. The patient has suffered from weakness of limbs and neck, poor activities, mental retardation, and inability to speak, accompanied by repeated convulsions for 3 years.

2. The patient suffered from weakness of the neck and lower muscular tension of the neck. Her neck could not erect. She was suffering from weakness of limbs and inability to hold any objects with hands. She could not turn over, sit down, climb, stand up, or walking, accompanied by poor activities and difficulty in self-movement. Her muscle strength of the limbs was Grade Ⅲ with lower muscular tension. She suffered from mental retardation, inability to recognize people, and poor response to outside, accompanied by sluggish expression and inability to speak. Sometimes she sipped figures, accompanied by crossed hands. Clinton levy and the Pap levy were both normal. Her tongue was slightly red with white greasy tongue coating. Her pulse was fine and weak.

3. in Dec. 2003, the patient was diagnosed with epilepsy. In Mar. 2004, she was diagnosed with cerebral palsy. According to the above information, from the view of TCM she was diagnosed with:

1. Cerebral palsy

2. Epilepsy

3. Gan syndrome

TCM considered that the deficiency of her parent’s essence-blood led to the insufficiency of fetal origin and malnutrition of fetus. Alternatively, when the mother was pregnant, due to fatigue, malnutrition, uterus infection, suffocation, premature and polyembryony, she made the fetus insufficiency of qi and blood, malnutrition leading to stagnation of meridian by phlegm stasis, and malnutrition of muscle and vessel. Therefore, qi and blood could not transfer to brains and limbs. Due to deficiency of kidney-qi, weak wilting sinews and bones, slow development, vacuity of spleen and weakness of qi, weakness of circulation of qi and blood, malnutrition of brains, and disharmony of spleen and stomach, all made inability to nourish the limbs and limp wilting limbs. The child was scared in fetus, or she was influenced by wind evil when she was born, which led to weakness of spleen-qi and liver wind and effulgent gallbladder fire. Therefore, the child suffered from convulsions of limbs’ muscle and vein, congenital defect of talent, and cerebral palsy by acquired malnutrition.

Doctor’s diagnosis: Congenital insufficiency of talent, deficiency of the liver and kidney

Doctor’s strategy: boosting qi and fortifying the spleen, enriching the liver and nourishing the kidneys

Variable in sagely spleen-fortifying brain-supplementing decoction

Doctor’s requirement: take six dosages herbal tea of the same prescription. One dosage a day and drink twice. Acupuncture and massage for once a day.

The patient should have more medical examinations if necessary.

Date:  July 7^th 2007                                 Time: 10:00 a.m.

Today the patient’s father did not complain about any other special discomfort of his baby. The child was still suffering from weakness of limbs and neck, poor activities, mental retardation, and inability to speak, accompanied by sometimes attacked by convulsions with stimulation. The examinations of blood and the function of her liver and kidney were all normal; antigen of Hepatitis B’s surface was normal. The examinations of ECG and lung were both normal. Her heart and lung were both normal, and her abdomen was soft and flat. No aversion to coldness. No fever, headache, dizziness, nausea or vomiting. Her spirit and appetite were both poor. Her sleep was normal. Her bowel movement and urination were both incontinent. Her tongue was slightly red with white-greasy tongue coating. Her pulse was deep and fine. Doctor’s requirement: The herbal tea should follow the original formulation.

Date:  July 8^th 2007                                 Time: 10:00 a.m.

Today the patient’s father did not complain about any other special discomfort of his baby. The child was still suffering from weakness of limbs and neck, poor activities, mental retardation, and inability to speak. The bowel movement was normal. The B-ultrasomotonography examinations of liver, gallbladder and kidneys were all normal. Examination: T 36.6℃，P 90 bpm, R 20bpm, K:16kg. Her heart and lung were both normal, her abdomen was soft and flat. Her spirit and appetite were improving. Her sleep was normal. Her bowel movement and urination were both incontinent. Her tongue was slightly red with white-greasy tongue coating. Her pulse was deep and fine. Doctor’s requirement: The herbal tea should follow the original formulation.

Date:  July 12^th 2007                                 Time: 9:00 a.m.

Today the patient’s father did not complain about any other special discomfort of his baby. The child was still suffering from weakness of limbs and neck, poor activities, mental retardation, and inability to speak. Examination: T 36.6℃，P 90 bpm, R 20bpm, K:16kg. Her heart and lung were both normal, her abdomen was soft and flat. Her spirit and appetite were both normal. Her sleep was good. Her bowel movement and urination were both incontinent. Her tongue was slightly red with white-greasy tongue coating. Her pulse was deep and fine. Doctor’s requirement: The herbal tea should follow the original formulation.

Date:  July 16^th 2007                                 Time: 9:00 a.m.

Today the patient’s mother did not complain about any other special discomfort of his baby. The child was still suffering from weakness of limbs and neck, poor activities, mental retardation, and inability to speak. Examination: T 36.6℃，P 90 bpm, R 20bpm, K:16kg. Her heart and lung were both normal, her abdomen was soft and flat. Her spirit and appetite were both normal. Her sleep was good. Her bowel movement and urination were both incontinent. Her tongue was slightly red with white-greasy tongue coating. Her pulse was deep and fine. Doctor’s requirement: The herbal tea should follow the original formulation.

Date:  July 20^th 2007                                 Time: 9:00 a.m.

Today the patient’s mother did not complain about any other special discomfort of his baby. The child was still suffering from weakness of limbs and neck, poor activities, mental retardation, and inability to speak. Examination: T 36.6℃，P 90 bpm, R 20bpm, K:16kg. Her heart and lung were both normal, her abdomen was soft and flat. Her spirit and appetite were both normal. Her sleep was good. Her bowel movement and urination were both incontinent. Her tongue was slightly red with white-greasy tongue coating. Her pulse was deep and fine. Doctor’s requirement: The herbal tea should follow the original formulation.

Date:  July 21^st 2007                                 Time: 9:00 a.m.

Today the patient’s mother did not complain about any other special discomfort of her baby. The child was still suffering from weakness of limbs and neck, poor activities, mental retardation, and inability to speak. The strength of her neck increased, and she could erect her neck. Examination: Her heart and lung were both normal, her abdomen was soft and flat. Her tongue was slightly red with white-greasy tongue coating. Her pulse was deep and fine. Doctor’s requirement: The herbal tea should follow the original formulation.

Date:  July 25^th 2007                                 Time: 16:00 a.m.

The patient’s mother complained that the child attacked by epilepsy four times yesterday. Today the child was attacked by epilepsy once at seven o’clock. The child’s spirit kept very poor and cried several times. Food in-take obviously decreased by about a half compared with yesterday. She only drank 60ml water. She did not take herbal tea today. Examination: T 36.2℃，heart rate was 122 / s without any noise. Sound of breath is bilaterally clear on auscultation. No rale of dryness-dampness. It is considered that the patient took too little food and water. Therefore, she was given 5%GS 250ml + Vitamin C 1g + Vitamin B6 50mg as intravenous injection, 20 drops a minute. She orally took potassium chloride 2 ml, three times a day.

Date:  July 29^th 2007                                 Time: 9:30 a.m.

Today the patient’s mother complained that the child’s epileptic attack decreased, but still sometimes with convulsions, 1 to 2 times a day for about 10 to 20 seconds every time. The child was still suffering from weakness of limbs, poor activities, and mental retardation. Sometimes she was able to pronounce “mom”. Examination: T 36.6℃，P 90 bpm, R 20bpm, K:16kg. Her heart and lung were both normal, her abdomen was soft and flat. Her spirit and appetite were better than before. Her sleep was normal. Her bowel movement and urination were both incontinent. Her tongue was slightly red with white-greasy tongue coating. Her pulse was deep and fine. Doctor’s requirement: The Chinese medicine should follow the original formulation. Western medicine added 5% glucose in water of 250ml and 10 ml injection solution for intravenous injection. The patient’s disease condition would be carefully examined.  

Date:  Aug. 2^nd 2007                                 Time: 9:00 a.m.

Today the patient’s mother complained that the child’s epileptic attack decreased. The child was still suffering from weakness of limbs, poor activities, and mental retardation. The reaction to outside increased slightly. Sometimes she was able to pronounce “Mom”. Examination: T 36.6℃，P 90 bpm, R 20bpm, K:16kg. Her heart and lung were both normal, her abdomen was soft and flat. Her spirit and appetite were better than before. Her sleep was good. Her bowel movement and urination were both incontinent. Her tongue was slightly red with white-greasy tongue coating. Her pulse was deep and fine. Doctor’s requirement: The Chinese medicine should follow the original formulation. Take five dosages herbal tea. Western medicine added 5% glucose in water of 250ml and 10ml injection solution for intravenous injection.

Date:  Aug. 7^th 2007                                 Time: 9:00 a.m.

Today the patient’s mother complained that the child’s epileptic attack decreased significantly. The child was still suffering from weakness of limbs, poor activities, and mental retardation. The reaction to outside got some improvement. Sometimes she was able to pronounce “Mom”. Examination: T 36.7℃，P 90 bpm, R 20bpm, K:18kg. Her heart and lung were both normal, her abdomen was soft and flat. Her spirit and appetite were better than before. Her sleep was good. Her bowel movement and urination were both incontinent. Her tongue was slightly red with white-greasy tongue coating. Her pulse was deep and fine. Doctor’s requirement: The Chinese medicine should follow the original formulation.

Date:  Aug. 12^th 2007                                 Time: 9:10 a.m.

The child was attacked by epilepsy once last night and once in this morning, which lasted for about 20 seconds. Her spirit was worse than before. No fever or vomiting. Her reaction was still dull. Her tongue was slightly red with thin and white tongue coating. Her pulse was deep and fine. Doctor’s requirement: The original formulation should add Bile arisaema root 4g and Bamboo sugar 4g to transform phlegm. The patient stopped acupuncture temporally. 

Date:  Aug. 16^th 2007                                 Time: 9:30 a.m.

The patient’s mother complained that the child could raise her head freely, but could not last too long. Her chewing and gulping became better than before. Her upper body could sit down for about 30 seconds. Doctor’s requirement: the Chinese medicine should follow the original formulation to nourish brains and fortify the spleen, dispel phlegm and extinguish the wind.

Date:  Aug. 18^th 2007                                 Time: 9:30 a.m.