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Brief Summary: On July 7, 2007, the MS patient Hanen from Saudi Arabia, who suffered from weakness and numbness of the lower limbs and unsteady walking, was hospitalized at our hospital. After 20-day TCM treatment, she has achieved significant improvement. She was very satisfied with the Chinese medicine treatment.

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Record of Hospitalization

Name: Hanen                                                                                                        Sex: Female

Age: 21                                                                                                                  Profession: Student

Nationality: Saudi Arabia                                                                                      Marital Status: Unmarried

Onset Season: Summer                                                                                         Date of Admission: July 7, 2007  

Complainer: The patient¡¯s herself                                                                           Reliability: Reliable

Major Complaint: The patient has suffered from weakness and numbness of the lower limbs for 4 years, and her condition has been aggravated by unsteady steps for one month.

Present Illness: In July 2003, the patient began to feel weakness and numbness of the lower limbs without any obvious causes, and the condition lasted for two weeks. At that time, the patient paid no attention to it, and did no treatment about it. A month later, the weakness and numbness of her lower limbs were aggravated, and then she went to a local hospital (unknown) for a diagnosis. After the examination, the patient was diagnosed with MS. The hospital gave her the treatment of ¡°interferon injection¡± for once every other day and prescribed ¡°ceftiofur sulfur trimethylamine¡± for orally taking 150mg each time and twice a day. The patient¡¯s condition was controlled. In June 2007, the patient¡¯s condition was suddenly aggravated. There appeared diplopia on her eyes. The weakness and numbness of her lower limbs were aggravated. She had difficulty in walking with unsteady steps, and she always fell down if no support was offered. She could not crouch or stand up. Then she went to a local hospital (unknown) for treatment, and was prescribed six days¡¯ cortisone for orally taking. She got some improvement, and her eyes¡¯ diplopia disappeared. To seek further comprehensive treatment, she was picked up by our staff to our hospital at 19:00 p.m. on July 7, 2007. Since she got the disease, her spirit and appetite have been both normal with slightly poor sleep. In a recent month, she had urinary incontinence with once bowel movement every three days.

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.

Personal History: She was born in Saudi Arabia, living in a dry environment. No contact history of schistosomiasis. No addiction to smoking, alcohol or special food. She was mild-tempered and open-minded.

Marital History: She has not been married yet.

Menstrual History: Her menstruation started at the age of 12. Generally, her menstrual period was five to six days every 28 to 30 days. Her last menstruation was on June 29, 2007. Her menses is in red with little amount, without any abnormal smell.

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

Physical Examination:

T 36.3¡æ£¬P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg,.

She grew normally with medium nutrition. 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 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation. Abdomen touched flat and soft without tenderness or rebounding 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 upper limbs. The lower limbs were suffering from weakness and numbness. She could not crouch or stand up, accompanied by unsteady walking. The Romberg levy was (+). Her muscle strength of the lower limbs was Grade ¢ó with muscular tension weakened. The examinations of anus and pudendum were both normal. The brinell levy was normal. Other physiological reflex has not been elicited. Her tongue was dull with yellow tongue coating. Her pulse was string-like and slippery.

Diagnostic examination: Not provided.

First Diagnosis: 

TCM diagnosis: Wilting syndrome

Symptom diagnosis: Deficiency of the liver and kidneys, liver wind entering network channels with qi vacuity.

Western medicine diagnosis: Multiple sclerosis (MS)

 

First Medical Record

July 7, 2007

Hanen, a 21-year-old female, has suffered from weakness and numbness of the lower limbs for 4 years, and her condition has been aggravated by unsteady steps for one month. She was picked up by our staff at Zhijiang airport, and arrived in Huaihua Red Cross Hospital for further treatment at 19: 00 p.m. on July 7, 2007.  

Essentials for diagnosis:

1. The patient has suffered from weakness and numbness of the lower limbs for 4 years, and her condition has been aggravated by unsteady steps for one month.

2. In July 2003, the patient began to feel weakness and numbness of the lower limbs without any obvious causes, and lasted for two weeks. At that time, the patient paid no attention to it, and did no treatment about it. A month later, the weakness and numbness of her lower limbs were aggravated, and then she went to a local hospital (unknown) for a diagnosis. After the examination, the patient was diagnosed with MS. The hospital gave her the treatment of ¡°interferon injection¡± for once every other day and prescribed ¡°ceftiofur sulfur trimethylamine¡± for orally taking 150 mg each time and twice a day. The patient¡¯s condition was controlled. In June 2007, the patient¡¯s condition was suddenly aggravated. There appeared diplopia on her eyes. The weakness and numbness of her lower limbs were aggravated. Besides, she had difficulty in walking with unsteady steps, and she always fell down if no support was offered. She could not crouch or stand up, and she had urinary incontinence. She went to a local hospital (unknown) for treatment, and was prescribed six days¡¯ cortisone for orally taking. She got some improvement, and her eyes¡¯ diplopia disappeared. To seek further comprehensive treatment, she was picked up by our staff to our hospital at 19:00 p.m. on July 7, 2007. Since she got the disease, her spirit and appetite have been both normal with slightly poor sleep. In a recent month, she had urinary incontinence with once bowel movement every three days.

3. T 36.3¡æ£¬P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg,.

4. She grew normally with common nutrition. 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 with clear mind.

5. The lower limbs were suffering from weakness and numbness. She could not crouch or stand up, and her condition was accompanied by unsteady walking. The Romberg levy was (+). Her muscle strength of the lower limbs was Grade ¢ó with muscular tension weakened. The brinell levy was normal.

6. No thoracic deformity. Chest percussion noted resonance. Sound of breath is bilaterally clear on auscultation. No sound of pleural friction rubs.

7. Diagnostic examination: Not provided.

Diagnostic Basis:

TCM: The patient has suffered from weakness and numbness of the lower limbs for 4 years, and her condition has been aggravated by unsteady steps for one month. The patient had deficiency of the liver and kidneys. The essence-blood could not nourish the muscles and vessels. Gradually it resulted in flaccidity syndrome. The loins are the residence of the kidneys, and the kidneys are in charge of the bones. The insufficiency of essence-marrow makes limbs wilting and makes the loins and knees weak. Her tongue was dull with yellow tongue coating. Her pulse was string-like and slippery. All these reflections belong to the scope of flaccidity syndrome.

Western medicine: The patient has suffered from weakness and numbness of the lower limbs for 4 years, and her condition has been aggravated by unsteady steps for one month. The lower limbs were suffering from weakness and numbness. She could not crouch or stand up. Besides, she walked unsteadily. The Romberg levy was (+). Her muscle strength was Grade ¢ó with muscular tension weakened. The patient was diagnosed with MS in her national hospital (unknown).

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 affected, though she usually has no joint pains. On the contrary, impediment syndrome is generally characterized by aching pains, fixed heaviness and inflexibility of the sinews, bones, muscles and joints, with occasional numbness or swelling, though, no paralytic manifestations exist. They are not difficult to be distinguished in clinics.

Western Medicine: Wilting syndrome should be differentiated from myasthenia gravis, which is a kind of acquired autoimmune disease that there appear transmitting obstacles in the site of neuromuscular junctions owing to the reduced acetylcholine receptor. Myasthenia gravis 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 and weakness of the striated muscles. It will be improved with rest or medicines that inhibit the activity of cholinesterase. It can also involve cardiac muscles and smooth muscles.

First Diagnosis: 

TCM diagnosis: Wilting syndrome

Symptom identification: Deficiency of the liver and kidneys, liver wind entering network channels with qi vacuity.

Western medicine diagnosis: MS

Plans for treatment strategy and nursing:

1. On routine care of traditional Chinese internal medicine.

2. On grade II care.

3. Under the care of a companion.

4. Regular diet.

5. Herbal tea (to supplement and boost liver and kidneys, to boost qi, to track down wind and to free the network channels): one dosage a day and drink twice.

Prescription: Varied formula of the Hidden Tiger Pill.

Main herbs used in the herbal tea: huangqi (astragalus root), shudi (cooked rehmannia root), gouqi (lycium), etc.

6. Acupuncture and massage: once a day.

7. Western medicine: Interferon injection (self-prepared) for twice a day;

8. Have more medical examinations if necessary.

 

Date:  July 8, 2007                                 Time: 9:00 a.m.

The patient did not complain about any other special discomfort to Dr. Yang, but she had weakness and numbness of the lower limbs, accompanied by unsteady walking.

Examination: T 36.4¡æ, P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg.

Her heart and lungs were normal, and her abdomen was soft and flat.

Dr. Yang¡¯s analysis:

1. The patient has suffered from weakness and numbness of the lower limbs for 4 years, and her condition has been aggravated by unsteady steps for one month.

2. The lower limbs were suffered from weakness and numbness. She could not crouch or stand up. Besides, she walked unsteadily. The Romberg levy was (+). Her muscle strength of the lower limbs was Grade ¢ó with muscular tension weakened. Her tongue was dull with yellow tongue coating. Her pulse was string-like and slippery.

3. In August 2003, the patient was diagnosed with MS in a national hospital (unknown). According to the above information, TCM diagnosed it as wilting syndrome which is characterized as retardation of the limbs¡¯ muscles and vessels, weakness of the limbs, difficulty in movement, accompanied by muscular atrophy. In clinics, this kind of disease affects lower limbs more often, which is also called ¡°crippling wilting¡±. The patients who are suffering from it feel weakness of the spleen and stomach, lack of sources of the qi and blood, which could not nourish the muscles and vessels, and so it forms wilting limbs. The kidneys are in charge of the bones. The insufficiency of essence-marrow makes the limbs wilting and makes the lumbus and knees weak.  

Doctor¡¯s diagnosis: Insufficiency of the liver and kidneys, and liver wind entering the network channels with qi vacuity. Doctor¡¯s strategy: supplementing and boosting the liver and kidneys, boosting qi, extinguishing wind and freeing the network channels.

Varied formula of the Hidden Tiger Pill.

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

Western medicine: Interferon injection (self-prepared) for twice a day. The patient should have more medical examinations if necessary.

 

Date:  July 9, 2007                                 Time: 9:00 a.m.

Today the patient did not complain about any other special discomfort and still felt the weakness and numbness of her lower limbs, accompanied by unsteady walking. The examinations of the blood and the function of her liver and kidneys were all normal; six items of hepatitis B and B.S were all normal. The examinations of ECG and the lungs were both normal. Her heart and lungs were normal, and her abdomen was soft and flat. Her spirit and diet were both normal. Her sleep was good. She was with urinary incontinence. Her bowel movement was normal. Doctor¡¯s requirement is that the herbal tea should follow the original formula.

 

Date:  July 10, 2007                                 Time: 10:00 a.m.

Today the patient did not complain about any other special discomfort and still felt the weakness and numbness of her lower limbs, accompanied by unsteady walking. The examinations of her stool and urine were both normal. Examination: T 36.3¡æ, P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg. Her heart and lungs were normal, and her abdomen was soft and flat. Her spirit and diet were both normal. Her sleep was good. Her urinary incontinence got some improvement. Her bowel movement was normal. Doctor¡¯s requirement is that the herbal tea should follow the original formula.

 

Date:  July 14, 2007                                 Time: 9:00 a.m.

Today the patient did not complain about any other special discomfort. The weakness of her lower limbs was improved, still with numbness, and her unsteady walking got some improvement. Examination: T 36.4¡æ, P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg. Her heart and lungs were normal, and her abdomen was soft and flat. Her spirit and diet were both normal. Her sleep was good. Her urinary incontinence almost disappeared. Her bowel movement was normal. Her tongue was dull with yellow tongue coating. Her pulse was string-like and slippery. Doctor¡¯s requirement is to take three dosages herbal tea of the same prescription. One dosage a day and drink twice. The herbal tea should follow the original formula.

 

Date:  July 18, 2007                                 Time: 9:30 a.m.

Today the patient did not complain about any other special discomfort. The weakness of her lower limbs was improved, still with numbness, and her unsteady walking got obvious improvement. Examination: T 36.4¡æ, P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg. Her heart and lungs were normal, and her abdomen was soft and flat. Her spirit and diet were both normal. Her sleep was good. Her bowel movement and urination were both normal. Her tongue was dull with yellow tongue coating. Her pulse was string-like and slippery. Doctor¡¯s requirement is that the herbal tea should follow the original formula.

 

Date:  July 22, 2007                                 Time: 9:30 a.m.

Today the patient did not complain about any other special discomfort. The weakness of her lower limbs was improved, the numbness of the lower limbs almost disappeared, and her unsteady walking got obvious improvement. Examination: T 36.4¡æ£¬P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg. Her heart and lungs were normal, and her abdomen was soft and flat. Her spirit and diet were both normal. Her sleep was good. Her bowel movement and urination were both normal. Her tongue was dull with yellow tongue coating. Her pulse was string-like and slippery. Doctor¡¯s requirement is that the herbal tea should follow the original formula.

 

Date:  July 26, 2007                                 Time: 9:30 a.m.

Today the patient did not complain about any other special discomfort. The weakness of her lower limbs was improved, the numbness of the lower limbs disappeared, and her unsteady walking achieved obvious improvement. Examination: T 36.4¡æ£¬P 78 beats/minute, R 18 times/minute, BP 120/80 mmHg. Her heart and lungs were normal, and her abdomen was soft and flat. Her spirit and diet were both normal. Her sleep was good. Her bowel movement and urination were both normal. Her tongue was dull with yellow tongue coating. Her pulse was string-like and slippery. The patient would leave the hospital tomorrow.

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