Brief Summary:
Fathia, from Sudan, has suffered from
weakness and numbness of the lower limbs for 8 years. After
one-month treatment in our hospital, her condition has been
improved a lot.
Record of Hospitalization
Name:
Fathia Sex:
Female
Age:
54 Profession: Civil servant
Nationality:
Denmark Marital Status:
Married
Onset
Season:
Summer Date of Admission:
May. 13, 2007
Complainer:
The
patient¡¯s husband Reliability: Reliable
Major
Complaint:
The patient has suffered from weakness and anaesthesia of the
double lower limbs for 8 years, and her condition has been
aggravated for 2 years.
Present Illness:
In
late April 1999, the patient began to feel weakness and
anaesthesia of the double lower limbs 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
slowly. In 2001, the patient¡¯s sister was diagnosed as MS. Then
the patient went to the local government hospital for
examination, too. After the examination of MRI, the patient was
diagnosed as MS. After that, she has been taking
Prednisolone,
azathioprine,
amantadine
and Vietnam E until now. However, her disease had no obvious
improvement. In 2005,
her condition was aggravated.
She had difficulty in walking accompanied by hypomnesia. She
still took no other treatment.
She came
to our hospital for further treatment on
May
13, 2007.
Since
she got the disease, her spirit, her appetite, and her sleep
were all poor.
Her bowel movement was
dry and
hard,
and her urination was incontinent and frequent.
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. With the
history of sore throat.
Personal History:
She
was born in Denmark, living in a dry environment. No contact
history of schistosomiasis. No addiction to smoking, alcohol or
special food. She was even-tempered and open-minded.
Marital History:
She
got married at the age of 21. She has given birth to three sons
and two daughters. Her husband and children have been healthy
all the time.
Menstrual History:
Her
menstrual onset was at her age of 15. Generally, her
menstrual period was three to five days every 28 to 30 days. Her
menelipsis was in 2003.
Family History:
Her
parents were both healthy. No family history of special disease.
The patient¡¯s sister suffered MS and died in 2005. The patient
herself complained the disease history, so it was reliable.
Physical Examination:
T 36.6¡æ£¬P
80 beats/minute, R 20 times/minute, BP 110/80 mmHg, W 71.5 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 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 78 times/minute. Cardiac
rhythm was regular. No pathological murmurs on
auscultation. Abdomen
touched 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
were suffered from weakness, anaesthesia and rigiditas.
Her muscle strength was Grade
¢ó
with muscle tension hypertonicity. The patient had difficulty in
walking. Other physiological reflex has not been elicited. Her
tongue was red and purple with yellow and deep tongue coating.
There were dental impressions in the margins of the tongue, and
there was spicule in the tongue root. Her pulse was thin and
week.
Diagnostic examination: Not provided.
First
Diagnosis:
TCM
diagnosis:
Wilting
syndrome
Symptom identification:
Depletion and vacuity of the spleen and kidneys, accompanied by
moist heat.
Western medicine diagnosis:
Multiple
sclerosis (MS)
First
Medical Record
May
13, 2007
Fathia, a 54-year-old female, has suffered from weakness and
anaesthesia of the double lower limbs for 8 years, and her
condition has been aggravated for 2 years. She was picked up by
our workers in Huaihua railway station and arrived in Huaihua
Red Cross Hospital for further treatment at 13: 00 p.m. on May
13, 2007.
Essentials for Diagnosis:
1.
The patient has suffered from weakness and anaesthesia of the
double lower limbs for 8 years, and her condition has been
aggravated for 2 years.
2. In
the late April 1999, the patient began to feel weakness and
anaesthesia of the double lower limbs without any obvious cause.
At that time, the patient paid no attention to it, and did no
treatment about it. Therefore, the disease was developing
slowly. In 2001, the patient¡¯s sister was diagnosed as MS. Then
the patient went to the local hospital for examination, too.
After the examination of MRI, the patient was diagnosed as MS.
After that, she has been taking
hydrogenated
nm,
azathioprine,
decane amine tricyclic and Vietnam E until now. However, her
disease had no obvious improvement. In 2005,
her condition was aggravated.
She had difficulty in walking accompanied by hypomnesia. She
still took no other treatment.
She came
to our hospital for further treatment on
May
13, 2007.
Since
she got the disease, her spirit, her appetite, and her sleep
were all poor.
Her bowel movement was dry and hard, and her urination was
incontinent and frequent.
3. T 36.6¡æ£¬P
80 beats/minute, R 20 times/minute, BP 110/80 mmHg, W 71.5 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 were suffered
from
weakness, anaesthesia and rigiditas. Her muscle strength was
Grade
¢ó with muscle tension hypertonicity. The patient had
difficulty in walking.
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.
Diagnostic Basis:
TCM:
The patient has suffered from weakness and anaesthesia of the
double lower limbs for 8 years, and her condition has been
aggravated for 2 years. Due to the
weakness of the spleen and stomach, deficiency of source of
the qi and blood, her essence-blood could not nourish her
organism. Therefore, she felt flaccidity of organism. Due to the
depletion and vacuity of the liver and kidneys, her
essence-blood could not nourish her sinews and vessels.
Gradually it resulted in flaccidity of kidneys, deficiency of
marrow, weakness of lower limbs and thin pulse. These are also
the reflections of depletion and vacuity of yin and blood.
Western medicine: The patient has suffered from weakness and
anaesthesia of the double lower limbs for 8 years, and her
condition has been aggravated for 2 years.
The double lower limbs were suffered from
weakness, anaesthesia and rigiditas. Her muscle strength was
Grade
¢ó with muscle tension hypertonicity. The patient had
difficulty in walking.
After the examination of MRI, the patient was diagnosed as MS in
her national 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 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 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
myasthenia gravis, which can occur at any age and there are
about 60 percent people stricken before 30 years old. Myasthenia
gravis is a kind of
autoimmune disease that there appear transmitting obstacles in
the
site of neuromuscular junction
owing to the reduced
acetylcholine receptor. Women are more often affected than men
are. The most obvious characteristic of MG is rapid fatigability
and weakness of the
striated
muscles part of the body or all over the body affected. It will
be improved with rest or medicines that
inhibit the activity of cholinesterase.
It can also involve
cardiac
muscle and smooth muscle.
First
Diagnosis:
TCM
diagnosis: Wilting syndrome
Symptom identification:
Depletion and vacuity of the spleen and kidneys, accompanied by
moist heat.
Western medicine diagnosis: MS
Plans
for treatment strategy and nursing:
1.
Routine care of traditional Chinese internal medicine.
2.
Grade II care.
3.
Under care of a companion.
4.
Low-protein diet.
5.
Herbal tea (to fortify the spleen and supplement the kidneys,
resolve heat
and disinhibit dampness): one dosage a day and drink twice.
Prescription:
Varied formula of the Four Gentlemen Decoction and Mysterious
Four Powders.
Main
herbs used in the herbal tea: huangqi (astragalus root),
dangshen (codonopsis root), fuling (poria), etc.
6.
Acupuncture and massage: once a day.
7.
Have more medical examinations if necessary.
Date:
May 14, 2007 Time: 9:00
a.m.
The
patient¡¯s husband complained to Dr. Zhang that the patient has
suffered from weakness and anaesthesia of the double lower limbs
for years, and her condition has been aggravated for 2 years.
The patient¡¯s double lower limbs were suffered from
weakness, anaesthesia and rigiditas. She had difficulty in
walking. She had lumbar myalgia with amnesia.
Her
urination is incontinent and frequent. She was with feet fever,
poor sleep and diet. Her mouth was dry.
She is with red and purple tongue,
yellow and deep tongue coating. There is indentation in the
edges of the tongue, and there is spicule in the ball of the
tongue. Her pulse is thin and week. She had
the history of frequent sore throat. (The patient¡¯s sister had
suffered MS and had been dead for two yeas.) After the diagnosis
of TCM, the patient was suffered from flaccidity syndrome, which
belonged to
depletion and vacuity of the spleen and kidneys, accompanied
with moist heat.
The patient should fortify the spleen and supplement the
kidneys, resolve heat
and disinhibit dampness.
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 15, 2007 Time:
10:00 a.m.
The patient did not
complain about any other special discomfort and still felt
her double lower limbs
weakness, anaesthesia and rigiditas. She still had difficulty in
walking. The
examination of the function of her liver and kidneys was normal,
and ESR was 18mm/n (+). Her sleep and diet were still poor. Her
bowel movement and urination are normal. Doctor¡¯s requirement is
to let the patient build confidence and keep an open-minded
moon. The herbal tea should follow the
original formula.
Date:
May 17, 2007 Time:
9:00 a.m.
Since
the patient taking our herbal tea in our hospital, her appetite
has increased gradually. Her sleep was still poor. She still had
frequent
micturition and urinary incontinence.
After the examination of her urine, her
OB
(occult blood) was +2. After the examination of microscope, her
MBC showed 3 to 8/HP, and her RBC was 2 to 5/ HP. It was
considered as urethral canal infection.
Date:
May 21, 2007 Time:
9:00 a.m.
Today
the patient¡¯s appetite was normal. Her sleep was not very good.
She had
frequent micturition and urgent micturition.
Her UPD was small. After the analysis
of urine and the examination of microscope, her RBC showed 5 to
8/HP.
her
OB (occult blood) +2. There was some urine in bladder after the
examination of B-ultrasonic. The patient had urinary
incontinence and urethral canal infection. Therefore, she need
use sanitary towel.
Date:
May 23rd 2007 Time:
9:00 a.m.
Today
the patient¡¯s appetite was normal. Her sleep was not very good.
Her frequent
micturition, urgent micturition and urinary incontinence were
not stable. Her ankle-joint was still
spastic.
Her double lower limbs were
still suffered from weakness and anaesthesia. She could
walk slowly and still forgetful.
Date:
May 26, 2007 Time:
9:00 a.m.
The
patient¡¯s frequent micturition and urgent
micturition got some improvement. She had three times urination
on average in the daytime and at night. Her difficulty in
walking also got some improvement. The patient¡¯s mood was rather
pleasant. After the examination of her urine, her
OB
(occult blood) showed +2. After the examination of microscope,
her MBC (+), and her RBC was 2 to 5/ HP. There is no obvious
improvement.
Doctor¡¯s
requirement is to take three dosages of the herbal tea of the
same prescription.
Date:
May 29, 2007 Time:
9:00 a.m.
The
patient¡¯s
frequent micturition and urgent micturition got further
improvement. Last night, she had only twice urination, without
enuresis. Her difficulty in
walking also got some improvement.
Doctor¡¯s requirement is to take four dosages of the herbal tea
of the same prescription.
Date:
June 2, 2007 Time:
9:00 a.m.
The
patient¡¯s
frequent micturition and urgent micturition got obvious
improvement.
She
had no
urinary incontinence. Her weak lower limbs and her difficulty in
walking got further improvement. Her sleep was still not very
good. Sometimes she felt dizzy and forgetful. The patient asked
for strengthening her memory.
Doctor¡¯s
requirement is to take four dosages of the herbal tea of the
same prescription. The prescription should increase acorus root
by 5 grams, spiny jujube kernel by 5 grams and polygala root by
5 grams.
Date:
June 6, 2007 Time:
9:00 a.m.
The
patient health condition got further improvement.
Doctor¡¯s
requirement is to take four dosages of the herbal tea of the
same prescription.
Date:
June 7, 2007 Time:
9:00 a.m.
Today
the patient¡¯ husband told the doctor that the patient health was
becoming better. Her mood was very pleasant. The patient still
wanted to stay for another month¡¯s treatment, but her family
condition disallowed her.
Date:
June 10, 2007 Time:
9:00 a.m.
The
patient¡¯s
frequent micturition and urgent micturition almost disappeared.
Last night, she only had once urination. She had no feelings of
urinary incontinence these days. Her sleep and her memory were
becoming better. The patient was in a positive mood. The
symptoms of weakness, anaesthesia and
rigiditas of her double limbs disappeared. She could take
big steps.
Doctor¡¯s requirement is to take four dosages of the herbal tea
of the same prescription.
Date:
June 14, 2007 Time:
9:00 a.m.
After our treatment of herbal tea, acupuncture and massage in
our hospital, the weakness,
anaesthesia and rigiditas of the patient¡¯s double limbs
were becoming better gradually. She has regained her health
completely so far. She could walk normally.
Her
frequent micturition, urgent micturition and urinary
incontinence disappeared. Her urination was normal. The symptoms
of forgetfulness and insomnia got obvious improvement. The
patient was in a very positive mood. The patient demanded to
leave the hospital today. Besides, she would like to take 60
dosages of the herbal tea of the same prescription home for
further treatment.
