Brief Summary:
Audra, from Lithuania, has suffered from
MS for 5 years. She came to our Red Cross Hospital on April 28,
2007 for our TCM treatment. After two month comprehensive
treatment, the patient has achieved about 30% improvement.
Record of Hospitalization
Name:
Audra Sex: Female
Age:
50
Profession: Surgeon
Nationality:
Lithuania Marital
Status: Married
Onset
Season:
Spring Date of
Admission: April 28, 2007
Complainer:
The patient¡¯s herself Reliability:
Reliable
Major
Complaint:
The
patient has suffered from
rigidity and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5
years, and her condition has been aggravated by disability of
walking for 2 years.
Present Illness:
In 2002, the patient began to feel
rigidity and weakness
of her double limbs¡¯ muscular without any obvious causes. At
that time, the patient paid no attention to it, and did no
treatment about it. Therefore, the disease was developing
progressively. After three months, she began to walk unsteadily,
and fell down frequently. Then the patient went to the local
hospital (unknown) for examination. After the examination of
MRI, the patient was diagnosed as MS. The doctor told the
patient there was no treatment for this kind of disease, so she
took no treatment. In October 2006, the patient began to be
unable to walk, and felt anaesthesia of her double lower limbs.
She began to use wheelchair. Then she started to take our herbal
tea by air shipping until now, and the anaesthesia of her double
lower limbs disappeared.
She came to our hospital for further treatment on
April
28, 2007.
Since
she got the disease, her spirit, her appetite, and her sleep
were all normal.
Her bowel movement and urination were normal.
Disease History:
She had hepatitis A when she was five yeas old,
and had cured. No history of typhoid, tuberculosis, malaria or
other infectious diseases. No allergic history of medicine or
food. No operation or trauma history. No history of blood
transfusion. No history of preventive vaccination provided.
Personal History:
She
was born in Lithuania. No contact history of schistosomiasis. No
addiction to alcohol or special food. She has smoked for 15
years, 20 cigarettes a day. She was even-tempered and
open-minded.
Marital History:
She got married at the age of 23. She has given birth to a
daughter. Her husband and her daughter have been healthy all the
time.
Menstrual history:
Her
menstrual onset was at her age of 14. Generally, her
menstrual period was 3 to 5 days every 28 to 30 days. Her
menelipsis was on March 27, 2003.
Family History:
Her parents are both healthy. No family history of special
disease.
Physical Examination:
T 36.4¡æ£¬P
80 beats/minute, R 21 times/minute, BP 110/80 mmHg, K 65 kg.
She grew normally with common nourishment. 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, 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
touches flat and soft without tenderness or rebounding
tenderness. The liver and spleen were not palpable. No
percussion pains in renal region. Bowel sound was normal. No
spinal and pelvic deformity or tenderness. No deformity or
inflexibility of the double upper limbs. The double lower limbs¡¯
muscular were suffered from rigidity and weakness. Her
ankle-joint of double knees was spastic with difficulty in
movement. Her double lower limbs were obviously weak. Her muscle
strength was Grade ¢ò
with muscle tension hypertonicity. Her anus and pudendum were
normal. Other physiological reflex has not been elicited. Her
tongue was dull with thin and white tongue coating. Her right
pulse was slippery and her left pulse was week.
Diagnostic Examination:
Not provided.
First
Diagnosis:
TCM
diagnosis:
Membra
rigidity (Wilting syndrome)
Symptom identification:
Depletion and vacuity of the liver and kidneys, and the liver
wind entering the network channels.
WM diagnosis: 1.Multiple sclerosis (MS)
2. Multiple obsolete cerebral infarctions
First
Medical Record
April
28, 2007
Audra, a 50-year-old female, has suffered from
rigidity
and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5
years, and her condition has been aggravated by disability of
walking for 2 years. She was picked up by our workers in
Zhijiang Airport and arrived at Huaihua Red Cross Hospital for
further treatment at 14: 00 p.m. on April 28, 2007.
Essentials for Diagnosis:
1.
The patient has suffered from
rigidity
and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5
years, and her condition has been aggravated by disability of
walking for 2 years.
2. In
2002, the patient began to feel
rigidity
and weakness
of her double limbs¡¯ muscular without any obvious causes. At
that time, the patient paid no attention to it, did no treatment
about it. Therefore, the disease was developing progressively.
After three months, she began to walk unsteadily, and fell down
frequently. Then the patient went to the local hospital
(unknown) for examination. After the examination of MRI, the
patient was diagnosed as MS. The doctor told the patient there
was no treatment for this kind of disease, so she took no
treatment. In October 2006, the patient began to be unable to
walk, and felt anaesthesia of her double lower limbs. She began
to use wheelchair. Then she began to take our herbal tea by air
shipping until now, and the anaesthesia of her double lower
limbs disappeared.
She came
to our hospital for further treatment on
April
28, 2007.
Since
she got the disease, her spirit, her appetite, and her sleep
were all normal.
Her bowel movement and urination were normal.
3. T 36.4¡æ£¬P
80 beats/minute, R 21 times/minute, BP 110/80 mmHg, K 65 kg
4.
She grew normally with common nourishment.
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.
5.
The double lower limbs¡¯ muscular were
suffered from
rigidity
and weakness. Her ankle-joint of double knees was spastic with
difficulty in movement. Her double lower limbs were obviously
weak. Her muscle strength was Grade
¢ò with muscle tension
hypertonicity.
6. No
thoracic deformity. Chest percussion noted resonance. Sound of
breath was bilaterally clear on auscultation. No sound of
pleural friction.
7.
Diagnostic examination: Not provided.
Diagnosis Basis:
TCM:
The patient has suffered from
rigidity
and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5
years, and her condition has been aggravated by disability of
walking for 2 years. Due to the
depletion and vacuity of the liver and kidneys, her
essence-blood could not nourish her sinews and vessels.
Gradually it formed flaccidity syndrome. The wilting syndrome
resulted in depletion of essence and blood, malnutrition of
channel sinew, deficiency of marrow and limp aching lumbus and
knees.
Western Medicine:
The double lower limbs¡¯ muscular were suffered from
rigidity and weakness. Her ankle-joint of double knees was
spastic with difficulty in movement. Her double lower limbs were
obviously weak. Her muscle strength was Grade
¢ò with muscle tension
hypertonicity.
After
the examination of MRI, the patient was diagnosed as MS in the
local government hospital.
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 flaccidity syndrome may even become
unable to hold an object or to stand without any support.
Besides, the patient¡¯s lower limbs are more often attracted,
though he or she usually has no joint pains. On the contrary,
impediment syndrome is generally characterized as aching pains,
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.
Western Medicine:
Wilting
syndrome
should be differentiated from sequela of apoplexy,
which refers to the remnant symptoms of different
severity of half-body paralysis, inhibited speech and slack
mouth and eyes after curing the apoplexia. It is mainly because
of cerebrovascular accident, cerebral ischemia or by oppressing
and moving of hematoma, cerebral edema, which destroy the
function of the brain tissues. For example, cerebral hemorrhage
often occurs in brain capsule, which can cause lusitropic
hemiplegia and the left-brain bleeding accompanied by aphasia.
The diagnosis to the disease is the cerebral vascular accident.
First
Diagnosis:
TCM
diagnosis:
Membra
rigidity
(Wilting syndrome)
Symptom identification:
Depletion and vacuity of the liver and kidneys, and the liver
wind entering the network channels.
Western
medicine
diagnosis: 1.Multiple Sclerosis (MS)
2. Multiple obsolete cerebral infarctions
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.
Pleasant diet.
5.
Herbal tea (to fortify and nourish the liver and kidneys,
extinguish wind and free the network channels.) one dosage a day
and drink twice.
Prescription:
Varied formula of the Major Wind-stabilizing Pill.
Main
herbs used in the herbal tea: baishao (white poney), ajiao (ass
hide glue), shengdi (fresh rehmannia root), etc.
6.
Acupuncture and massage: once a day.
7.
Have more medical examinations if necessary.
Date:
April 29, 2007 Time:
9:00 a.m.
Today
the patient complained to Dr. Yang that
her double lower limbs¡¯ muscular were suffered from
rigidity
and weakness. She was unable to walk.
The
examination of the function of her liver and kidneys was normal,
and the examination of BS, and
electrolyte blood-fat were all-normal.
Examination:
T 36.4¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg, K 65 kg.
Her
heart and lungs were normal and her abdomen was soft and flat.
Dr.
Yang¡¯s analysis:
1.
The patient has suffered from
rigidity
and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5
years, and her condition has been aggravated by disability of
walking for 2 years.
2.
The double lower limbs¡¯ muscular were
suffered from
rigidity
and weakness. Her ankle-joint of double knees was spastic with
difficulty in movement. Her double lower limbs were obviously
weak. Her muscle strength was Grade
¢ò
with muscle tension hypertonicity.
3.
After
the examination of MRI, the patient was diagnosed as MS in her
national hospital. Flaccidity syndrome is characterized as limp,
weak, and emaciated limbs with
muscular atrophy.
The patient could not move freely. Due to the
depletion and vacuity of the liver and kidneys, her
essence-blood could not nourish her sinews and vessels.
Gradually it formed flaccidity syndrome. The flaccidity syndrome
resulted in depletion of essence and blood, malnutrition of
channel sinew, deficiency of marrow and limp aching lumbus and
knees.
Doctor¡¯s diagnosis:
Depletion and vacuity of the liver and kidneys, and the liver
wind entering the network channels.
Doctor¡¯s strategy: To fortify and nourish the liver and kidneys,
extinguish wind and free the network channels.
Doctor¡¯s requirement is to take two dosages of the 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:
April 30, 2007
Time: 14:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Today, she had a MRI
examination of her brain and neck at No.2 hospital in
Huaihua. The results were as follows: 1. There exists multiple
ischemic focus in the bilateral basal ganglia, bilateral centrum
semiovale, bilateral occipital lobe, the left cerebral peduncle,
and double Juxtaventricular. 2. There exist multiple obsolete
cerebral infarctions on her right occipital lobe and bilateral
centrum semiovale. 3. Degeneration of the cervical vertebra. 4.
C4/5, C5/6 protrusion of ntervertebral
disc. 5. Degeneration and atrophy of the cervical vertebra.
According to above disease information, it is sure that the
diagnosis of TCM is correct. The patient should continue the
treatment to fortify and nourish the liver and kidneys,
extinguish wind and free the network channels, accompanied by
the treatment of acupuncture and massage.
Date:
May 1, 2007 Time:
9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs
were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit,
her appetite, and her sleep were all normal. Her bowel movement
and urination were normal. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left
pulse was weak. Doctor¡¯s requirement is to take three dosages of
the herbal tea of the same prescription. One dosage a day and
drink twice.
Date:
May 5, 2007 Time:
9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs
were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit,
her appetite and her sleep were all normal. Her bowel movement
and urination were normal. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left
pulse was week. Doctor¡¯s requirement is to take herbal tea of
the same prescription. One dosage a day and drink twice.
Date:
May 8, 2007 Time:
9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs
were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit,
her appetite and her sleep were all normal. Her bowel movement
and urination were normal. Her tongue was red with thin and
white tongue coating. Her right pulse was slippery and her left
pulse was week. Doctor¡¯s requirement is to take herbal tea of
the same prescription. One dosage a day and drink twice.
Date:
May 13, 2007 Time:
9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs
were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit,
her appetite and her sleep were all normal. Her bowel movement
and urination were normal. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left
pulse was week. Doctor¡¯s requirement is to take five dosages of
the herbal tea of the same prescription. One dosage a day and
drink twice.
Date:
May 18, 2007 Time:
9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs
were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit,
her appetite and her sleep were all normal. Her bowel movement
and urination were normal. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left
pulse was week. Doctor¡¯s requirement is to take herbal tea of
the same prescription. One dosage a day and drink twice.
Date:
May 22, 2007 Time:
9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk. Her heart and lungs
were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit,
her appetite and her sleep were all normal. Her bowel movement
and urination were normal. Her tongue was dull with thin and
white tongue coating. Her right pulse was slippery and her left
pulse was week. Doctor¡¯s requirement is to take five dosages the
herbal tea of the same prescription. One dosage a day and drink
twice.
Date:
May 27, 2007 Time:
9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.7¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her heart and lungs were normal, and her abdomen was soft and flat.
The examination of her double lower limbs was the same as
before. Her spirit, her appetite and her sleep were all normal.
Her bowel movement and urination were normal. Her tongue was
dull with thin and white tongue coating. Her right pulse was
slippery and her left pulse was week. Doctor¡¯s requirement is to
take herbal tea of the same prescription. One dosage a day and
drink twice.
Summary Stage
Date:
May 28, 2007 Time:
10:00 a.m.
Audra, a 50-year-old female, has suffered from
rigidity
and weakness
of her double limbs¡¯ muscular and from walking unsteadily for 5
years, and hercondition has been aggravated by disability of
walking for 2 years. She was picked up by our workers in
Zhijiang Airport, and she arrived at Huaihua Red Cross Hospital
for further treatment at 14: 00 p.m. on April 28,
2007.
Physical examination:
T 36.7¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg, K 65 kg.
She has developed
normally with medium nutrition.
Her mind was clear. She has an expression of chronic illness and
languidness. She was in a positive posture and cooperative in
examination. Her heart and lungs were normal, and her abdomen
was soft and flat. The
double lower limbs¡¯ muscular were suffered from rigidity
and weakness. Her ankle-joint of double knees was spastic with
difficulty in movement. Her double lower limbs were obviously
weak. Her muscle strength was Grade
¢ò
with
muscle tension hypertonicity. Her spirit, her appetite and her
sleep were all normal. Her bowel movement and urination were
normal.
First
diagnosis:
TCM
diagnosis:
Membra
rigidity (flaccidity syndrome)
Symptom identification:
Depletion and vacuity of the liver and kidneys, and the liver
wind entering the network channels.
Western medicine diagnosis: Multiple Sclerosis
(MS)
The process of treatment: the patient has taken our herbal tea to
fortify and nourish the liver and kidneys, to extinguish wind
and free the network channels
since
she arrived at our hospital. The prescription:
One
dosage a day and drink twice. Take 100ml herbal tea each time.
Do the treatment of acupuncture and massage once a day. The
patient¡¯s health condition was becoming better.
The
current situation:
Her
spirit, her appetite and her sleep were all normal. Her bowel
movement and urination were normal.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg, K 65 kg.
Her heart and lungs were normal, and her abdomen was soft and flat.
She
suffered from the muscular
rigidity and weakness of the lower limbs. Her ankle-joint of double knees was spastic with difficulty in
movement. Her double lower limbs were obviously weak. Her muscle
strength was Grade
¢ò
with muscle tension hypertonicity. Her tongue was light red with
thin and white tongue coating. Her pulse was slippery.
Current diagnosis:
TCM
diagnosis:
Membra
rigidity (flaccidity syndrome)
Symptom identification:
Depletion and vacuity of the liver and kidneys, and the liver
wind entering the network channels.
Western medicine diagnosis: Multiple Sclerosis
(MS)
Plans
for treatment strategy and nursing:
1.
Continue taking herbal tea to fortify and nourish the liver and
kidneys, extinguish wind and free the network channels.
2.
Acupuncture and massage: once a day.
3.
Take exercise of the function of the double lower limbs once a
day.
4.
Keep open-minded mood and pleasant spirit.
Date:
June 2, 2007 Time: 9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her heart and lungs
were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit,
her appetite and her sleep were all normal. Her bowel movement
and urination were normal. Her tongue was dull with thin and
white tongue coating. Her pulse was slippery. Doctor¡¯s
requirement is to take herbal tea of the same prescription. One
dosage a day and drink twice.
Date:
June 7, 2007 Time:
9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her heart and lungs were normal, and her abdomen
was soft and flat. The examination of her double lower limbs was
the same as before. Her spirit, her appetite and her sleep were
all normal. Her bowel movement and urination were normal. Her
tongue was dull. Her pulse was slippery. Doctor¡¯s requirement is
to take five dosages of the herbal tea of the same prescription.
One dosage a day and drink twice.
Date:
June 12, 2007 Time: 9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her heart and lungs
were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit,
her appetite and her sleep were all normal. Her bowel movement
and urination were normal. Her tongue was dull. Her pulse was
slippery. Doctor¡¯s requirement is to take herbal tea of the same
prescription. One dosage a day and drink twice.
Date:
June 17, 2007 Time:
9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her heart and lungs
were normal, and her abdomen was soft and flat. The examination
of her double lower limbs was the same as before. Her spirit,
her appetite and her sleep were all normal. Her bowel movement
and urination were normal. Her tongue was dull. Her pulse was
slippery. Doctor¡¯s requirement is to take herbal tea of the same
prescription. One dosage a day and drink twice.
Date:
June 22, 2007 Time:
9:00 a.m.
The patient did not complain about any other
special discomfort and still complained that
her double lower limbs¡¯ muscular were suffered from rigidity and
weakness, and she was still unable to walk.
Examination: T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 120/75 mmHg.
Her heart and lungs were normal, and her abdomen was soft and
flat. The examination of her double lower limbs was the same as
before. Her spirit, her appetite and her sleep were all normal.
Her bowel movement and urination were normal. Her tongue was
dull. Her pulse was slippery. The patient would leave the
hospital today.
