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Records
of Hospitalization
Name:
Janos
Sex: Male
Age:
40 Profession:
Chauffeur
Nationality:
Hungary Marital status: Divorced
Onset
Season: Summer
Date of Admission: Nov. 20th 2007
Complainer: The patient¡¯s
himself Reliability: Reliable
Major
complaint: The patient has
suffered from diplopia repeatedly for 14 years, and has been aggravated by
weakness of both lower limbs along with walking unsteadily for 5 years.
Present illness:
In Nov. 1994, the patient suddenly appeared diplopia, and then he went to a
local hospital for a diagnosis. After the MRI examination, he was diagnosed with
MS. He didn¡¯t take any treatment. Later, his eyesight recovered. After his
diplopia disappeared, he was attacked by the same symptoms repeatedly, sometimes
serious sometimes light. In Nov. 2002, the patient began to appear the weakness
of both lower limbs with unsteady walking. He could only walk with the support
of the crutches, but he still took no treatment. In Mar. 2004, he began to take
the injection of Interferon once a month up to now. To seek for further
treatment, he arrived at our hospital on Dec. 20th 2007. Since he got
the disease, his spirit and appetite were both normal. His sleep was sound. 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 food or medicine. No history of blood transfusion. No
history of preventive vaccination. In July 1998, his Right elbow suffered from
traumatic fracture, and cured after the surgery of internal fixation. Next year,
he took another surgery for the extraction of internal fixation. In 2003, his
left elbow suffered from traumatic fracture and received the surgery of internal
fixation. Then in the next year, he was cured after taking another surgery for
the extraction of internal fixation.
Personal
history: he was born in
Hungary, living in a dry environment. No contact history of schistosomiasis. No
addiction to smoking or alcohol. He was mild-tempered and open-minded.
Marital
history: he got married at
23. Now, he has a daughter and a son. Both of them are healthy.
Family
history: his aunt has
suffered from MS. Now she is still under the treatment. No other family history
of inherited disease.
Physical
examination:
T 36.1¡æ£¬P
80 bpm, R 20 bpm, BP 110/70mmHg
He was
mid-nourished and normally developed. His mind was clear. 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 enlargement of his tonsils. With soft neck
and trachea placed in the middle. No enlargement
of the thyroid gland. No turgor in jugular vein. No thoracic
deformity. Sound of breath was bilaterally normal on auscultation. No
respiratory rales or pleural friction rubs. No apophysis of the precordial
region. Heart border was normal. Heart beat 80 times/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. No deformity or
inflexibility of his upper limbs. His lower limbs suffered from weakness with
unsteady walking. His walking was supported by the crutches. . The muscle
strength of lower limbs was Grade
¢ó
with normal muscle tension. His eyesight declined, and appeared diplopia when
looking at something. He didn¡¯t take the examinations to the anus and pudendum.
His physiological reflex exists. The pathological symptoms have not been
elicited. His tongue was dark with thin and white tongue coating. His pulse was
vacuous and stringlike.
Diagnostic
examination: Not provided
First
diagnosis:
TCM
diagnosis: Wei-syndrome (Flaccidity syndrome)
Symptom
diagnosis: Deficiency of the liver and kidneys, accompanied with malnutrition of
sinews and vessels.
WM
diagnosis: Multiple sclerosis (MS)
First
Medical Record
Nov. 20th
2007
Janos, a
40-year-old male, has suffered from diplopia repeatedly for 14 years, and has
been aggravated by weakness of both lower limbs along with walking unsteadily
for 5 years. He was picked up by our staff at Zhijiang Airport and arrived in
Huaihua Red Cross Hospital for further treatment at 20:00 p.m. on Nov. 20th
2007.
Essentials
for diagnosis:
1. The
patient has suffered from diplopia repeatedly for 14 years, and has been
aggravated by weakness of both lower limbs along with walking unsteadily for 5
years.
2. In Nov. 1994, the patient suddenly
appeared diplopia, and then he went to a local hospital for a diagnosis. After
the MRI examination, he was diagnosed with MS. He didn¡¯t take any treatment.
Later, his eyesight recovered. After his diplopia disappeared, he was attacked
by the same symptoms repeatedly, sometimes serious sometimes light. In Nov.
2002, the patient began to appear the weakness of both lower limbs with unsteady
walking. He could only walk with the support of the crutches, but he still took
no treatment. In Mar. 2004, he began to take the injection of Interferon for
once a month up to now. To seek for further treatment, he arrived at our
hospital on Dec. 20th 2007. Since he got the disease, his spirit and
appetite were both normal. His sleep was sound. His bowel movement and urination
were both normal.
3. T 36.1¡æ£¬P
80 bpm, R 20 bpm, BP 110/70mmHg
4. He was
mid-nourished and normally developed. His mind was clear. He was in a positive
position and cooperative in examination.
5. No
thoracic deformity. Chest percussion noted resonance. Sound of breath is
bilaterally clear on auscultation. No sound of pleural friction.
6.
Diagnostic examination: In June of 1999, after the examination of MRI, he was
diagnosed with MS in a capital hospital of his own country.
7.
Diagnostic examination: Not provided
Diagnostic basis
TCM:
The patient has suffered from diplopia repeatedly for 14 years, and has been
aggravated by weakness of both lower limbs along with walking unsteadily for 5
years. It belongs to vacuity of liver-kidneys, so the blood-essence could not
nourish the sinews and vessels. Since the lumber is the house of kidneys and the
kidneys are in charge of the bones, lack of the essence results in limp aching
lumbus and knees and weakness of the lower limbs. While deficiency of the blood
essence could not nourish the eyes, so he could not see objects clearly with
diplopia. His tongue was dark with thin and white tongue coating. His pulse was
vacuous and stringlike. All the symptoms belong to the scope of Wei-syndrome.
Western
medicine:
The patient
has suffered from diplopia repeatedly for 14 years, and has been aggravated by
weakness of both lower limbs along with walking unsteadily for 5 years. His
eyesight declined, and appeared diplopia when looking at something.
His lower limbs suffered from weakness with
unsteady walking. He was able to walk with the support of the crutches. In 1994,
he was diagnosed with MS after the MRI examination 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 seriously may even become unable to hold an object 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 CNS virus infection. CNS virus
infection is always characterized as cephalitis or meningitis. However, it
seldom involves brainstem, cerebellum, spinal cord and optic nerve. The patient
got the disease rapidly always with the symptoms of headache, fever, coma,
convulsions and meningeal irritation.
First
diagnosis:
TCM
diagnosis: Wei-Syndrome
(Flaccidity syndrome)
Symptom
diagnosis: Deficiency
of the liver and kidneys, accompanied with malnutrition of
tendon and vessel.
WM
diagnosis: MS
Plans 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. Regular
diet
5. Herbal
tea (to supplement and boost the liver and kidneys, to sooth the sinews and free
the vessels): one dosage a day and drink twice
Main herbs
in three dosages herbal tea: Gou qi (Lycium), Shu di (Cooked Rehmannia root),
Zao pi (Cornus fruit), etc.
6.
Acupuncture and massage: once a day
7. Have
more medical examinations if necessary
Date: Nov.
21st 2007 Time: 9:30 a.m.
Today the
patient complained to Dr. Yang that he could not see objects clearly with
diplopia, accompanied with weakness of his lower limbs and unsteady walking. The
examination to the blood and urination were both normal. The examination to the
function of his liver and kidneys were also normal.
Examination: T 36.1¡æ£¬P
80 bpm, R 20 bpm, BP 110/70mmHg.
His heart
and lung were normal, and his abdomen was soft and flat.
Doctor
Yang¡¯s analysis:
1. The
patient has suffered from diplopia repeatedly for 14 years, and has been
aggravated by weakness of both lower limbs along with walking unsteadily for 5
years.
2. His
eyesight declined, and appeared diplopia when watching something.
His lower limbs suffered from weakness with
unsteady walking, and he could only walk with the support of the crutches.
3. In 1994,
after the examination of MRI, he was diagnosed with MS in a local hospital.
According to the above information, TCM
considered it as Wei-syndrome (Flaccidity syndrome). It is due to vacuity of
liver-kidneys, so the blood-essence could not nourish the sinews and vessels.
Since the lumber is the house of kidneys and the kidneys are in charge of the
bones, lack of the essence results in limp aching lumbus and knees and weakness
of the lower limbs. While deficiency of the blood essence could not nourish the
eyes, so he could not see objects clearly with diplopia. His tongue was dark
with thin and white tongue coating. His pulse was vacuous and weak. Doc. Yang
analyzed that it belonged to deficiency of the liver and kidneys, which resulted
in malnutrition of sinews and vessels.
Principle of TCM treatment:
supplementing and boosting the liver and kidneys, soothing the sinews and
quickening the vessels.
Herbal tea
prescribed for three days including Gouqi (Lycium), Shudi (Cooked Rehmannia
root), Zaopi (Cornus fruit), etc. One dosage a day and drink twice.
Doctor¡¯s
requirement: take three dosages of herbal tea of the above prescription.
Acupuncture and massage for once a day. The patient will have more medical
examinations if necessary.
Date: Nov.
22nd 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still said that he
appeared diplopia when watching some objects, accompanied with weakness of his
lower limbs and unsteady walking. His heart and lung were normal, and his
abdomen was soft and flat. He kept normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was dark with thin and white
tongue coating. His pulse was feeble and stringlike. Doctor¡¯s requirement: The
herbal tea should follow the original formulation.
Date: Nov.
23rd 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still said that he
appeared diplopia when watching some objects, accompanied with weakness of his
lower limbs and unsteady walking. His heart and lung were normal, and his
abdomen was soft and flat. He kept normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was dark with thin and white
tongue coating. His pulse was feeble and stringlike. Doctor¡¯s requirement: The
herbal tea should follow the original formulation.
Date: Nov.
28th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort and still said that he
appeared diplopia when watching some objects, accompanied with weakness of his
lower limbs and unsteady walking. His heart and lung were normal, and his
abdomen was soft and flat. He kept normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was dark with thin and white
tongue coating. His pulse was feeble and stringlike. Doctor¡¯s requirement: The
herbal tea should follow the original formulation.
Date: Dec.
3rd 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that his diplopia
disappeared, and the weakness of his lower limbs improved significantly and his
unsteady walking also got better. His heart and lung were normal, and his
abdomen was soft and flat. His spirit and appetite were both normal, and his
sleep was sound. His bowel movement and urination were both normal. His tongue
was red with thin and white tongue coating. His pulse was feeble and stringlike.
Doctor¡¯s requirement: The herbal tea should follow the original formulation.
Date: Dec.
8th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that his diplopia
disappeared, and the weakness of his lower limbs improved significantly and his
unsteady walking also achieved obvious improvement. His heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
good, and his sleep was sound. His bowel movement and urination were both
normal. His tongue was red with thin and white tongue coating. His pulse was
vacuous and stringlike. Doctor¡¯s requirement: The herbal tea should follow the
original formulation.
¡¡
Date: Dec.
13th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that his diplopia
disappeared, and the weakness of his lower limbs improved significantly and his
unsteady walking also achieved obvious improvement. His heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
good, and his sleep was sound. His bowel movement and urination were both
normal. His tongue was red with thin and white tongue coating. His pulse was
feeble and stringlike. The patient demanded to leave hospital today. |
