Records of Hospitalization
Name: Qamar
Sex: Male
Age:
60 Profession: Engineer
Nationality: Pakistan
Marital status: Married
Onset Season: Summer
Date of Admission: July 9th 2007
Complainer: The patient
himself Reliability: Reliable
Major complaint: The
patient has suffered from spasm and weakness of his limbs for seven years and
aggravated by fibrillation
and atrophy
of his muscles
for eight months.
Present illness: In Oct.
of 2000, the patient began to feel spasm and weakness of his limbs accompanied
with some difficulties in movement without any obvious causes. Then the patient
went to a local hospital for a diagnosis, and was diagnosed with motor neuron
disease. The detailed treatment was unknown. In Mar. of 2006, after the EMG
examination, he was diagnosed with multifocal motor neuropathy, accompanied by
the transferring stagnation of left Ulna, left central artery and right Ulna. In
the following 4 to 6 weeks, he continuously took immunoglobulin three times.
Each time he took the medicine for five days, and 250 ml each day. After taking
the immunoglobulin, he felt his spasm was well controlled. In Sep. of 2006, he
took a further EMG examination, the symptoms of transferring stagnation
disappeared, and he was diagnosed with motor neuron disease. Over the past 6
weeks, he had taken Riluzole, 50 ml each day.
To seek for a further comprehensive
treatment, he arrived in our hospital at 19: 00 on July 9th 2007.
Since he got the disease, his spirit and sleep were both poor. His appetite was
good. His bowel movement and urination were both normal.
Disease history: No
history of typhoid, tuberculosis, hepatitis, malaria or other infectious
disease. No allergic history of medicine or food. No trauma history. History of
preventive vaccination not provided.
Personal history: he was
born in Pakistan. No contact history of schistosomiasis. No addiction to
smoking, alcohol or special food. He was mild-tempered and open-minded.
Marital history: he got
married at 30. He had no child.
Family history: No
family history of special disease.
Physical examination:
T 36.2¡æ£¬P:
80bpm, R: 18bpm, BP: 140/80 mmHg,
He was mid-nourished and normally
developed. His mind was clear. He had an expression of chronic illness and
languidness. He was in a positive position and cooperative in examination. His
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 deformity of skull
and the five sense organs.
No congestion in throat. No
swollen tonsil. With soft neck and trachea placed in the middle. No enlargement
of the thyroid gland. No congestion of the jugular vein.
No thoracic deformity. Sound of
breath was bilaterally normal on auscultation. No respiratory rales or pleural
friction rubs. Heart border was normal. Heart beat 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 and
ribs
were not
palpable. No percussion pain in renal region. Bowel sound was normal. No spinal
and pelvic deformity or tenderness. He suffered spasm and weakness of the limbs
along with obvious muscular atrophy of his arms.
The
muscle strength of his
upper limbs was Grade
¢ó.
The grip
of his left hand was 6 kg, and that of the right hand was 10 kg.
Since his fingers were suffered from
weakness so that he could neither hold any fine objects nor write with pens.
The experiment on his hands was (+). There was no obvious atrophy on his
lower limbs. His anklebones were stiff. He felt his legs weak as walking. His
lower limbs could raise 40 degrees, with inflexible movement. The reflection of
his knee jumping was normal. Brinell levy was (-), Barthel levy was (-), and
Babinski levy also was (-).There were muscles trembling all over his body. He
felt weak and tired, accompanied by limp wilting lumbus and knees, purple
eyes-orbit, and pale face. His tongue coating was very little with red and
purple tongue body. There were teeth marks on the edge of his tongue. His pulse
was deep, fine and weak.
Diagnostic examination: Not provided.
First
diagnosis:
TCM
diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom diagnosis: wind-stasis blocks the sinews and vessels, accompanied by
deficiency of liver and kidneys, and malnutrition of sinews and vessels.
WM
diagnosis: Motor Neuron
Disease
First
Medical Record
July 9th 2007
Qamar,
a 60-year-old male, has suffered from spasm and weakness of his limbs for seven
years and aggravated by
fibrillation and atrophy
of his muscles
for eight months. He was picked up by our staff in Zhijiang Airport and arrived
in Huaihua Red Cross Hospital for further treatment at 19: 30p.m on July 9th
2007.
Essentials for diagnosis:
1. The
patient has suffered from spasm and weakness of his limbs for seven years and
aggravated by fibrillation
and atrophy
of his muscles
for eight months.
2.
In Oct. of 2000, the patient
began to feel spasm and weakness of his limbs accompanied with some difficulties
in movement without any obvious causes. Then the patient went to a local
hospital for a diagnosis, and was diagnosed with motor neuron disease. The
detailed treatment was unknown. In Mar. of 2006, after the EMG examination, he
was diagnosed with multifocal motor neuropathy, accompanied by the transferring
stagnation of left Ulna, left central artery and right Ulna. In the following 4
to 6 weeks, he continuously took immunoglobulin three times. Each time he took
the medicine for five days, and 250 ml each day. After taking the
immunoglobulin, he felt his spasm was well controlled. In Sep. of 2006, he took
a further EMG examination, the symptoms of transferring stagnation disappeared,
and he was diagnosed with motor neuron disease. Over the past 6 weeks, he had
taken Riluzole, 50 ml each day.
To seek for a further comprehensive
treatment, he arrived in our hospital at 19: 00 on July 9th 2007.
Since he got the disease, his spirit and sleep were both poor. His appetite was
good. His bowel movement and urination were both normal.
3. T
36.2¡æ£¬P:
80bpm, R: 18bpm, BP: 140/80 mmHg,
4. He
was mid-nourished and normally developed. His mind was clear. He had an
expression of chronic illness and languidness. He was in a positive position and
cooperative in examination.
5.
He was suffering from spasm and weakness,
accompanied by muscular atrophy of his arm. The
muscle strength of his
upper limbs was Grade
¢ó.
The grip of his left hand was 6 kg, and that of the right hand was 10 kg.
Since his fingers were suffered from
weakness so that he could neither hold any fine objects nor write with pens.
The experiment on his hands was (+). There was no obvious atrophy on his
lower limbs. His anklebones were stiff. He felt his legs weak as walking. His
lower limbs could raise 40 degrees, with inflexible movement. The reflection of
his knee jumping was normal. Brinell levy was (-), Barthel levy was (-), and
Babinski levy also was (-).
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
spasm and weakness of his limbs for seven years and aggravated by
fibrillation and
atrophy
of his muscles
for eight months. Because of the deficiency of the liver and kidneys, so the
essence-blood could not nourish his sinews and vessels. Then it leads to the
malnutrition of the muscles, and gradually it resulted in flaccidity. Lumbar is
the house for kidneys, and the kidneys is in charge of the bones. Since the
insufficiency of essence, he felt his lumbus and knees limp and weak,
accompanied by muscle wasting. And since deficiency of liver and kidneys, the
wind stasis blocks the sinews and vessels.
Western medicine: The patient has suffered from spasm and weakness of his limbs
for seven years and aggravated by
fibrillation and
atrophy
of his muscles
for eight months. He was suffering from
spasm and weakness, accompanied by muscular atrophy of his arm. The
muscle strength of his
upper limbs was Grade
¢ó.
The grip of his left hand was 6 kg, and that of the right hand was 10 kg.
Since his fingers were suffered from
weakness so that he could neither hold any fine objects nor write with pens.
The experiment on his hands was (+). There was no obvious atrophy on his
lower limbs. His anklebones were stiff. He felt his legs weak as walking. His
lower limbs could raise 40 degrees, with inflexible movement. The reflection of
his knee jumping was normal. Brinell levy was (-), Barthel levy was (-), and
Babinski levy also was (-). In Sep. of 2006, he was diagnosed with
Motor Neuron Disease in a local
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 any objects or
to stand without any support. Besides, the patient¡¯s lower limbs are more often
affected, 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 is an acquired autoimmune
disease with the transferring obstacles of nerve-muscles, and is caused by the
autoimmune reaction resulting from the acetylcholine receptor (AchR) of the
striated muscle. It 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. It can involve cardiac muscle and smooth muscle. 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: wind-stasis blocks the sinews and vessels, accompanied by
deficiency of liver and kidneys, and malnutrition of sinews and vessels.
WM
diagnosis: Motor Neuron
Disease
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, to quicken the blood, to free the network vessels, to
soften the liver, to supplement the kidneys and extinguish the wind): taking
four dosages herbal tea and one dosage a day and drink twice
Prescription: Variable in Major Wind-Stabilization Pill
Main
herbs used in the herbal tea: Shudi(Cooked Rehmannia root), Huangqi (Astragalus
root), Dansheng (Salvia root), etc.
6.
Acupuncture and massage: once a day
7.
Have more medical examinations if necessary
Date:
July 10th 2007 Time: 11:00 a.m.
The patient has suffered from spasm
and weakness of his limbs for seven years and aggravated by
fibrillation and
atrophy
of his muscles
for eight months. The patient was suffering from weakness of fingers and had
difficulty in holding
chopsticks. His upper limbs
and fingers were all with obviously muscular atrophy. His legs and ankle joints
were stiff, so he had difficulty in walking. There was muscular trembling all
over his body, accompanied with limp wilting lumbus and knees, purple
eyes-orbit, and pale face. His tongue coating was very little with red and
purple tongue body. There were teeth marks on the edge of his tongue. His pulse
was deep, fine and weak.
TCM
diagnosis: Wei-zheng (Flaccidity syndrome)
Symptom diagnosis: wind-stasis blocks the sinews and vessels, accompanied by
deficiency of liver and kidneys, and malnutrition of sinews and vessels.
WM
diagnosis: Motor Neuron
Disease
Principle of TCM treatment:
boosting qi, quickening the blood,
freeing the network vessels, softening the liver, supplementing the kidneys and
extinguishing the wind
Doctor¡¯s requirement: take four dosages of herbal tea of the same prescription.
Date:
July 13th 2007 Time: 10:00 a.m.
Today the patient had the functions
of his liver and kidneys examined. After the ECG and
B-ultrasomotonography
examination, it shows that his
Uric acid ammonia was higher to
10.1. He would continue to take the examination if necessary. In the B-ultrasomotonography
examination, it was found he suffered enlargement of prostate. There was no
other abnormity. After the treatment of herbal tea, accompanied by acupuncture
and massage, he felt his stiff lower limbs lessened. Doctor¡¯s requirement:
He would continue to take
five dosages herbal tea of the former prescription, and add Cornus fruit 15g.
Date:
July 18th 2007 Time: 9:00 a.m.
The
patient¡¯s condition kept stable. There were no special changes, and the doctor
advised him to add Peach kernel and Carthamus flower into the former herbal tea,
and do more exercise, especially for the suffering parts.
Date:
July 23rd 2007 Time: 9:00 a.m.
Today
the patient said that his muscular trembling lessened, and the stiff lower limbs
were getting better. However, there were no obvious improvement on the weakness
of his fingers and the difficulty in holding objects. The treatment strategy is
to boost qi, to quicken the blood, to soften the stiffness, to supplement the
kidneys and extinguish the wind. Doctor¡¯s requirement: take five dosages herbal
tea of the same formulation.
Date:
July 28th 2007 Time: 9:00 a.m.
Today
the patient complained that his condition was getting worse. The improvement was
not significant enough. The doctor advised him to do more functional exercise,
and change the herbal tea as following: the main herbs in five dosages herbal
tea: Taoren( Peach kernel), Baisheng(White Ginseng), Honghua(Carthamus), etc.
Date:
July 30th 2007 Time: 9:00 a.m.
Today
the patient complained that his fingers were weak and had difficulty in
movement, especially worse on his left hand. The doctor advised him to use the
external medicine for soaking his hands. The main herbs in the three dosages
external herbal tea as follow: Ground Pine, Sargentodoxa stem, Cinnamon twig,
etc.
Date:
Aug. 2nd 2007 Time: 9:00 a.m.
The
muscular trembling all over his body lessened. His lower limbs was stiff,
especially his right leg. He felt his back was stiff, and he had difficulty in
raising his legs and walking. The doctor advised him to do more exercise and
take more nutrition food. We strengthen the formula mainly to quicken the blood
and soften the stiffness.
Date:
Aug. 6th 2007 Time: 9:00 a.m.
Today
the patient said that the muscular trembling all over his body lessened
significantly, his hip joints
pain caused by trauma
improved obviously. The doctor advised him to add Spiny Jujube kernel in the
herbal tea for oral taking, combined five dosages herbal tea for external use
for soaking his hands.
Date:
Aug. 7th 2007 Time: 9:00 a.m.
Today
the patient complained that the muscular trembling all over his body lessened,
but his lower limbs were still stiff and
spastic.
The weakness of his fingers improved.
Doctor¡¯s requirement: take
the herbal tea of the same formulation.
Date:
Aug. 9th 2007 Time: 10:00 a.m.
Qamar,
a 60-year-old male, has suffered from spasm and weakness of his limbs for seven
years and aggravated by
fibrillation and atrophy
of his muscles
for eight months. He was picked up by our staff in Zhijiang Airport and arrived
in Huaihua Red Cross Hospital for further treatment at 19: 30p.m on July 9th
2007. He has hospitalized for 30 days here.
Admission situation:
He was
mid-nourished and normally developed. His mind was clear. He had an expression
of chronic illness and languidness. He was in a positive position and
cooperative in examination. Examination: T 36.2¡æ£¬P:
80bpm, R: 18bpm, BP: 140/80 mmHg, His heart and lung were normal. His abdomen
was soft and flat. He was suffering from
spasm and weakness, accompanied by muscular atrophy of his arm. The
muscle strength of his
upper limbs was Grade
¢ó.
The grip of his left hand was 6 kg, and that of the right hand was 10 kg.
Since his fingers were suffered from
weakness so that he could neither hold any fine objects nor write with pens.
The experiment on his hands was weak in (+). There was no obvious atrophy
on his lower limbs. His anklebones were stiff. He felt his legs weak as walking.
His lower limbs could raise 40 degrees, with inflexible movement. The reflection
of his knee jumping was normal. Brinell levy was (-), Barthel levy was (-), and
Babinski levy also was (-).
Admission diagnosis:
TCM
diagnosis: Wei-zheng (Flaccidity syndrome)
Symptom diagnosis: wind-stasis blocks the sinews and vessels, accompanied by
deficiency of liver and kidneys, and malnutrition of sinews and vessels.
WM
diagnosis: Motor Neuron
Disease
The
process of the diagnosis:
After the patient hospitalized in
our hospital, he was prescribed with herbal tea to boost qi, to quicken the
blood, to free the network vessels, to soften the liver, to supplement the
kidneys and extinguish the wind. The prescription was variable in Atractylodes
and Ovate Atractylodes Decoction, and Major Wind-Stabilization Pills. One dosage
a day and drink twice. Acupuncture and massage: once a day. The patient¡¯s
condition improved.
Current condition:
The muscular trembling all over his
body lessened, and the weakness of his fingers improved. The examination to his
hands, the grip of his left hand is 14.3kg, and that of his right hand is 18.7.
The muscular atrophy of his hands got no marked changes. The
muscle strength of his
upper limbs was Grade
¢ó,
and the muscle strength of
his lower limbs was Grade
¢ó.
The movement of his ankle joints got better than before. His tongue coating was
very little with red and purple tongue body. There were teeth marks on the edge
of his tongue. His pulse was deep, fine and weak.
Current diagnosis:
TCM
diagnosis: Wei-zheng (Flaccidity syndrome)
Symptom diagnosis: wind-stasis blocks the sinews and vessels, accompanied by
deficiency of liver and kidneys, and malnutrition of sinews and vessels.
WM
diagnosis: Motor Neuron
Disease
Plan
for treatment strategy and nursing
1.
Continue to take the herbal tea
2.
Acupuncture and massage: once a day
3. The
functional exercise on the lower limbs
4.
Keep a pleasant mood and be open-minded
His
fingers of the hands were with muscular atrophy and poor movement of the
fingers. The oral taking herbal tea should combine with five dosages herbal tea
for the external use. The main herbs in the herbal tea for external use are
Cinnamon twig, Ground Pine, Millettia root and stem, etc.
Date:
Aug. 11th 2007 Time: 9:30 a.m.
The
weakness of his lower limbs and the muscular trembling all over his body both
lessened. But sometimes his condition repeated. The doctor advised him to
continue five dosages herbal tea of the former prescription.
Date:
Aug. 16th 2007 Time: 9:30 a.m.
There were no special changes on
the patient¡¯s condition. The doctor advised him to get the injection of Tangkuei
as Acupoint injection, one bottle a day. The herbal tea should follow the former
prescription adding Dioscorea root 20g into it.
Date:
Aug. 18th 2007 Time: 9:00 a.m.
The
muscular trembling all over his body both lessened. He was still suffering form
the weakness of his fingers, especially his left hand. The lower limbs were
stiff, accompanied by some pain. The doctor advised him to take the former
herbal tea adding Corydalis tuber and Aconite main tuber into it, combined with
6 dosages herbal tea for soaking his hands.
Date:
Aug. 21st 2007 Time: 9:00 a.m.
The
patient was suffering form the weakness if his lower limbs, accompanied by
stiffness of his legs with some slight pain.
Doctor¡¯s requirement: take
three dosages herbal tea of the same prescription for oral taking.
Date:
Aug. 24th 2007 Time: 9:00 a.m.
The patient complained that his
right foot was terminal varus and had difficulty in walking. There was no
significant improvement on his weakness and atrophy fingers. The muscular
trembling and stiff legs improved a lot. Doctor¡¯s requirement: take four dosages
herbal tea of the same prescription.
Date:
Aug. 28th 2007 Time: 9:00 a.m.
The patient himself felt the
strength of the lower limbs increased. The muscular trembling all over his body
also lessened. Doctor¡¯s requirement: take three dosages herbal tea of the same
prescription.
Date:
Aug. 31st 2007 Time: 9:00 a.m.
The
patient¡¯s ankle joints of the right foot were stiff and
varus.
Doctor¡¯s requirement: take five
dosages of herbal tea of the same prescription adding Peach kernel, combined
with three dosages herbal tea for soaking his hands.
Date:
Sep. 3rd 2007 Time: 9:00 a.m.
The
patient was suffering from pains of neck and shoulders. It got worse in
movement. The doctor advised him to take an X-ray examination to make sure
whether there were any lesions on his
cervical spine. The muscular
trembling on his arms was light in the daytime and worse at night. His other
condition was normal.
Date:
Sep. 5th 2007 Time: 9:00 a.m.
Today the patient got the
examination to the cervical
lateral films. His cervical
physiological curvature changes straight to 3 to 7. There were bone spurs around
his centrum. It was
considered to be cervical degenerative lesions. The stiffness and varus
of his right ankle joints
improved. He continued to soak his hands with the herbal tea for external use
and the herbal tea for oral taking.
Date:
Sep. 10th 2007 Time: 9:00 a.m.
The
patient was preparing to travel and demanded to take 5-day honey pills for oral
taking. The main herbs in honey pills: Angelica root, Astragalus root, Peach
kernel, etc.
Date:
Sep. 14th 2007 Time: 9:00 a.m.
Today the patient went to Xi¡¯an for
traveling and took 5-day honey pills for oral taking. He would continue to take
herbal tea after coming back to the hospital.
Date:
Sep. 19th 2007 Time: 09:00 a.m.
During
the travel, the patient¡¯s condition was normal. The muscular all over his body
worsened. He felt some discomfort of his neck since he fell to the ground during
travel. He continued to take the same prescription as that of Sep. 5th,
adding Notoginseng root into it.
Date:
Sep. 22nd 2007 Time: 9:00 a.m.
The
patient himself said that his lower limbs walked very well. The muscular
trembling sometimes repeated, and it got better after massage. Because of the
dry environment of northern area, the patient felt his nose was very dry. The
doctor advised him to take 6 dosages herbal tea the same as that of Sep. 19th.
Date:
Sep. 25th 2007 Time: 9:00 a.m.
After
the treatment of the herbal tea, acupuncture and massage, the spasm and weakness
of the patient¡¯s limbs, accompanied with muscular atrophy, muscular trembling
all over his body, and stiffness of his legs ankle joints all achieved
significant improvement. He demanded to leave the hospital and take 3 months
herbal tea for home taking.
The
main herbs in 60 dosages herbal tea for home taking: White Peony, Astragalus
root, Peach kernel, etc.
The
main herbs in 10-day honey pills: White Peony, Carthamus flower, Notoginseng
root, etc.
And
another 30-day herbal tea will prescribe to him according to his improvement and
will send it to him by air shipping.
Date:
Sep. 28th 2007 Time: 9:00 a.m.
The
patient¡¯s condition was good. Today the patient took 2-month herbal tea and left
the hospital. The doctor advised him to keep a stable mood and a pleasant
spirit, do some functional exercise, increase the nutrition food and continue
the treatment. 
