¡¡Brief Summary:
On June 18, 2008, George,
from Tanzania,
who suffered from poor
activities of the lower limbs and weakness all over the body, was hospitalized
in our hospital. He has
achieved much improvement after 60-day TCM treatment here. When he was here, it
si hard for him to walk upward a step on the stairs. During treatment, he could
walk upward at least 20 steps on the stairs.
Record
of Hospitalization
Name: George
Sex: Male
Age:
13 Profession: Student
Nationality:
Tanzania Marital Status: Unmarried
Onset Season: Grain
rain
Date of Admission: June 18, 2008
Complainer: The
patient¡¯s father Reliability: Reliable
First Medical Record
Date:
June 18, 2008 Time: 19.00 p.m.
George, a 13-year-old male, has suffered from poor activities of the lower limbs
for 8 years, and his condition has been aggravated by the weakness all over the
body for 3 years. He was hospitalized in our hospital for further treatment at
19: 30 p.m.on June 18, 2008.
Essentials for Diagnosis:
1. The
patient has suffered from poor activities of the lower limbs for 8 years, and
his condition has been aggravated by the weakness all over the body for 3 years.
2. 8
years ago, the patient began to suffer from the weakness of the right limb
without any obvious causes, which caused his inconvience in activities and
walking. With the time going by, his condition was aggravated. Then he was
diagnosed with DMD after the EMG examination in a local hospital. Now, the
patient can¡¯t walk steadily with staggering and
waddling gait. It is easy for him to fall down. He suffered from weakness all
over the body and had difficulty in raising his upper limbs. Sometimes he had
the symptoms of putting out his tongue and running at the mouth. His food intake
was poor with much sleep. He felt that there were some slight aching pains in
the joints all over the body. His bowel movement urination was normal,but his
urinationwas incontinent.
3. T
36.2¡æ£¬P
80 beats/minute, R 20 times/minute, BP 110/60 mmHg, K 70 kg.
4. He
grew normally with obese shape. His mind was clear. He had an expression of
chronic illness and languidness. His body was in a passive posture and he was
cooperative with clear mind.
5.
His gait was staggering in wadding gait.
The appearance of the gastrocnemius, deltoid,
infraspinatus and gluteus were enlarged. His pulse was thready and weak. The
body of his tongue was enlarged with white tongue coating. The gripping power of
his left hand was 4.9 kg, and that of the right hand was 8.2 kg.
6.
Diagnostic examination: The EMG shows ¡°DMD¡±.
Diagnostic Basis:
TCM
(Traditional Chinese Medicine): The patient has suffered from poor activities of
the lower limbs for 8 years, and his condition has been aggravated by the
weakness all over the body for 3 years. The patient can¡¯t walk steadily with
staggering and waddling gait. It is easy for him to
fall down. He suffered from weakness all over the body and had difficulty in
raising his upper limbs. Sometimes he had the symptoms of putting out his tongue
and running at the mouth. His food intake was poor with much sleep. He felt that
there were some slight aching pains in the joints all over the body. His bowel
movement was normal,but his urinationwas inwntinent. His pulse was thready and
weak. The body of his tongue was enlarged with white tongue coating.
According to the symptoms of his
tongue and pulse, it is shown that due to vacuity of the spleen and kidneys,
deficiency of the qi and blood, the patient¡¯s limbs were weak. He is mainly
characterized by weak limbs and dysfunction of the limbs. So it is believed as
wilting.
Western Medicine: The patient has suffered from poor activities of the lower
limbs for 8 years, and his condition has been aggravated by the weakness all
over the body for 3 years. The gripping power of his
left hand was 4.9 kg, and that of the right hand was 8.2 kg.
His gait
was staggering in wadding gait. The appearance of the
gastrocnemius, deltoid, infraspinatus and were enlarged is obese.
The EMG shows ¡°DMD¡±.
Diagnostic Differentiation:
TCM
(Traditional Chinese Medicine): The patient¡¯s
wilting
syndrome should be differentiated
from impediment syndrome.
Wilting syndrome is
characterized by limp, weak, and emaciated limbs with muscular atrophy. A
patient suffered from
Wilting syndrome seriously
may even become unable to hold an object or to stand without any support.
Besides, the patient usually has no joint pains. On the contrary, impediment
syndrome is generally characterized by aching pains, fixed heaviness and
inflexibility of sinews and 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 (MG), which is an
acquired autoimmune disease with the transferring obstacles owing to
the reduced
acetylcholine receptor in
the site of neuromuscular junction. It can occur at any age. The most
obvious characteristic of MG in clinics is rapid fatigability during the
movement of the skeletal muscles, which will be improved by rest or
cholinesterase. They are not
difficult to be distinguished in clinics.
First Diagnosis:
TCM
(Traditional Chinese Medicine) diagnosis:
Wilting
syndrome
Symptom identification: Vacuity of the spleen and kidneys.
Western Medicine diagnosis:
DMD
Plans
for treatment strategy and nursing:
1.
Routine care of traditional Chinese internal medicine.
2.
Grade II care.
3.
Under the care of a companion.
4.
Low-fat and high-protein diet.
5.
Herbal tea (to boost qi, fortify the spleen and supplement the kidneys): one
dosage a day and drink twice.
Main
herbs used in the herbal tea: baisheng (white ginseng),
baishu (ovate atractylodes root), fuling (poria),
etc.
6.
Acupuncture and massage: once a day.
7. Do
functional exercise for all the limbs.
8.
Have more medical examinations if necessary.
Date:
June 19, 2008 Time: 15:00 p.m.
The
patient¡¯s father said that his son had suffered weakness of all the limbs with
difficulty in walking for 8 years. Besides, he was sleepy and somnolent with
obese shape. He had difficulty in walking. What¡¯s more, his gait was staggering
in wadding gait. After his crouch, he had difficulty in standing up. He had a
large amount of food-intake. His urination was incontinent, but his bowel
movement was normal. The body of his tongue was slight red and
enlarged
with white and slimy thick tongue coating. His pulse was deep, thready and weak.
The TCM diagnosed it as wilting syndrome, while western medicine diagnosed it
with progressive DMD. Due to vacuity of the spleen and kidneys, the TCM
treatment strategy is to boost qi, fortify the spleen and supplement the
kidneys. The prescription was as follows: baisheng (white
ginseng), baishu (ovate atractylodes root),
fuling (poria), etc. 4 dosages in total.
Date:
June 22, 2008 Time: 9:00 a.m.
The
patient¡¯s urination was incontinent, so he had once
bed-wetting last night. He was still somnolent with poor spirit. He slept for 12
to 14 hours a day. He felt heaviness and fatigue all over the body. What¡¯s more,
there were slight aching pains in the joints all over the body. The prescription
was kept the same. 5 dosages in total.
Date:
June 27, 2008 Time: 9:00 a.m.
The
patient himself felt that the weakness of all his limbs got some improvement.
Besides, his father found that all the activities of his son were much more
flexible than before. His somnolence, fatigue, and difficulties in walking and
activities all got obvious improvement, so was the incontinent urination. In
recent days, he hasn¡¯t had any phenomenon of bed-wetting. Now, the amount of his
activities was increasing. He kept a good spirit. But he still felt weakness of
the loins, the double lower limbs and the joints. He still had difficulty in
standing up after a crouch. The TCM treatment strategy kept boosting qi,
fortifying the spleen and supplementing the kidneys. The former prescription was
changed a little. 5 dosages in total.
¡¡
Date:
July 2, 2008 Time: 9:00 a.m.
Since
the patient felt weakness of all the limbs with over-weight shape, he had
difficulty in walking. The doctor advised him to decrease the diet, especially
gradually to avoid some fatty food. He should do more exercise and sleep less.
His incontinent urination has almost disappeared. The doctor added bushy
knotweed root into his last prescription. 5 dosages in total.
¡¡
Date:
July 7, 2008 Time: 9:00 a.m.
His
difficulties in walking and activities got further improvement, so did his
somnolence and fatigue. His sleep also decreased to 10 hours a day. The amount
of his activities was increased a lot. He seldom had symptoms of bed-wetting. He
still felt weakness of the loins. His bowel movement was normal. His pulse was
deep, thready and weak. The prescription was changed as follows: dansheng
(salvia root), gancao( licorice root), zaopi( cornus fruit), etc. 5 dosages in
total.
Date:
July 12, 2008 Time: 9:00 a.m.
In the
past, it was easy for the patient to fall down when he walked. These days, there
was no phenomenon of falling down when he tried to walk. His other condition
kept steady. The formula was kept the same 3 dosages in total.
Date:
July 17, 2008 Time: 9:00 a.m.
The patient seldom had symptoms of
bed-wetting. His father said that the strength of his son¡¯s loins had been
increased a lot. He could get up and stand up by himself. The doctor again
changed his prescription a little. 5 dosages in total.
Date:
July 22, 2008 Time: 9:00 a.m.
The
patient¡¯s condition kept steady. His weight was decreased by 2 kg after
one-month hospitalization. His father had asked him not to lose weight too
quickly, and it isn¡¯t helpful for him to recover. His prescription was again
changed a little. 5 dosages in total.
Date:
July 27, 2008 Time: 9:00 a.m.
The difficulties in walking and
activities were further improved. Under the company of his father, he was able
to go up the stairs and go down the stairs twice a day. He kept a pleasant mood.
No falling down when he tried to walk. No bed-wetting. His diet and sleep were
both normal. He kept the same prescription. 5 dosages in total.
Date:
Aug 1, 2008 Time: 9:00 a.m.
The patient¡¯s condition kept
normal. His walking and activities were much easier and more flexible than
before. He has never fallen down in these days. His incontinent urination has
disappeared. He didn¡¯t felt obvious fatigue. He kept the same formula. 5 dosages
in total.
Date:
Aug 5, 2008 Time: 9:00 a.m.
The strength of his double lower
limbs and the loins was increased a lot. He was able to go up from the third
floor to the fifth floor. These days, he had no symptoms of bed-wetting. He
sometimes would fall down. He still felt weakness of the joints, so he couldn¡¯t
crouch. He could raise his upper limbs easily. The formula would be kept the
same. 5 dosages in total.
Date:
Aug 11, 2008 Time: 9:00 a.m.
His condition kept normal. He would
kept the same formula. 7 dosages in total.
¡¡
Date:
Aug 16, 2008 Time: 9:00 a.m.
The patient¡¯s condition kept
steady. Since his visa was expired, he would leave the hospital tomorrow.
¡¡
