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Brief Summary: On Apr. 11, 2009, Nikola from Bulgaria, who has suffered from repeated convulsion for 6 years and depravation of the condition for 1 year, was hospitalized in our hospital. He has achieved much improvement since there was no convulsion during 46 days when he stayed here.

 

Record of Hospitalization

Name: Nikola                                                                                                     Birthplace: Bulgaria

Sex: Male                                                                                                           Profession: Businessman

Age: 24                                                                                                              Date of Admission: Apr. 12, 2009

Nationality: Bulgaria                                                                                          Date of Record: Apr. 12, 2009

Marital Status: Unmarried                                                                                Onset Season: Vernal equinox

Complainer: The patient himself

 

First Medical Record

Date: Apr. 12, 2009                                       Time: 1: 00 a. m.

Nikola, a 24-year-old male, has suffered from repeated convulsion for 6 years and depravation of the condition for 1 year. He was hospitalized in our hospital at 1: 00 a. m. on Apr. 12, 2009.

Essentials for Diagnosis:

1. The patient has suffered from repeated convulsion for 6 years and depravation of the condition for 1 year.

2. In April 2003, the patient began to twitch without obvious reasons, so he was given examination in the local hospital and was diagnosed with epilepsy. Then he was in hospital for 1 month and took antiepileptic drug for the treatment. His condition was controlled properly, but it attacked every 1-3 months and it lasted for 2-3 minutes after leaving the hospital. He didn¡¯t take any other treatment except for antiepileptic drug. In recent one year, the patient felt his condition became worse. In order to search for the further treatment, he came to our hospital at 1: 00 a. m. on Apr. 12, 2009. His tongue was red with stasis speckles on the tongue. His tongue coating was thin and yellow. His pulse was weak.

3. T 36.4¡æ, P 80 times/minute, R 20 times/minute, BP 130/78mmHg.

4. He grew normally with common nutrition. His mind was clear. He had an expression of chronic illness and tiredness. His body was in a positive posture and he was cooperative with clear mind.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. He fell down suddenly when the disease attacked, accompanied with the symptoms of unclear spirit-mind, convulsion and drooling. The patient had the sense before the attack.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient has suffered from repeated convulsion for 6 years and depravation of the condition for 1 year. The repeated attacks of epilepsy and wind yang harassing resulted in consumption of liver-kidney yin. Liver wind with phlegm, clouding of the orifices of the heart and uselessness of spirit light brought about the symptoms of sudden falling down, unclear spirit-mind and convulsion. Wind-phlegm upsurging caused phlegm-drool profuse. So he was diagnosed with epilepsy.

Western Medicine: The patient has suffered from repeated convulsion for 6 years and depravation of the condition for 1 year. He fell down suddenly when the disease attacked, accompanied with the symptoms of unclear mind, convulsion and drooling. In April 2003, he was diagnosed with epilepsy in the local hospital.

Diagnostic Differentiation:

TCM: The patient¡¯s epilepsy should be differentiated from spasm. Both of the diseases have the symptom of convulsion. However, if one suffers from spasm, the convulsion attacks frequently, mostly accompanied by the symptom of fever. So they are not difficult to be distinguished.

Western Medicine: The patient¡¯s epilepsy should be differentiated from tremor, which is a kind of regular and continuous shivering of the limbs or head, etc. Tremor will attack repeatedly after the patient being stimulated or tiredness. But there is no change of the spirit-mind and convulsion of the limbs. It mostly occurs in middle-aged people. So they are not difficult to be distinguished.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Epilepsy pattern

Symptom identification: obstruction of wind-phlegm, yin vacuity of the liver and kidneys.

Western Medicine diagnosis: Epilepsy

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. Common diet.

5. TCM treatment strategy: transform stasis, dissipate binds, supplement essence, replenish the marrow, settle heaviness and quiet spirit.

6. Herbal tea: one dosage a day and drink twice.

Main herbs used in the herbal tea: faxia (pro formula pinellia), huangqi (astragalus root), etc.

7. Acupuncture and massage: once a day.

8. Have more medical examinations if necessary.

 

Date: Apr. 14, 2009                                      Time: 16: 00 p. m.

The patient said that his condition was generally good. His diet and sleep both were normal. There was no any discomfort of his body. The prescription was as follows: faxia (pro formula pinellia), huangqi (astragalus root), etc. 3 dosages in total.

 

Date: Apr. 17, 2009                                      Time: 12: 00 a. m.

His diet, sleep and spirit were good. The stasis speckles on the tongue were less than before. The prescription was changed as follows: zexie (alisma tuber), danggui (tangkuei), etc. 3 dosages in total.

 

Date: Apr. 20, 2009                                      Time: 12: 00 a. m.

His diet, sleep and spirit were good. There was no abnormity or any discomfort. He didn¡¯t feel the headache. Continue to take the same prescription. 1 dosage in total.

 

Date: Apr. 21, 2009                                      Time: 15: 00 p. m.

The patient has suffered from congenital cysts, accompanied with the symptom of occasional headache. Usually, his epilepsy would attack every 2-3 months. There were small red sores and boils on his chest, back, head and face. He felt the mouth dry. His tongue was red-purple. His tongue coating was yellow with scant fluids. His pulse was weak. So the treatment strategy was to boost qi, quicken the blood circulation, dispel phlegm, extinguish wind, clear heat and resolve toxin. The last attack was on Jan. 31. The prescription was as follows: chuanxiong (ligusticum root), danshen (salvia root), etc. 4 dosages in total.

 

Date: Apr. 25, 2009           

His condition was generally good. The color of the sores and boils on his chest, back, head and face became light. His diet and sleep were normal. Continue to take the same prescription. 5 dosages in total.

 

Date: Apr. 30, 2009

The patient was given the examination in Beijing Medical University and the doctors here considered it as glioma of ganglion cell. He didn¡¯t feel headache after hospitalization. Besides, there was no attack of the disease for 3 months since January 31. His diet and sleep both were normal. The symptoms of dry mouth and red-purple tongue were improved. The prescription was changed as follows: gancao (licorice root), zhebeimu (zhejiang fritillaria bulb), etc. 5 dosages in total.

 

Date: May 5, 2009

There were no the symptom of headache and the attack of the disease for 95 days since last time. His sleep, diet, urine and bowel movement were normal. His tongue was red. The prescription was changed as follows: chuanxiong (ligusticum root), ezhu (zedoary), etc. 5 dosages in total.

 

Date: May 10, 2009

His common condition was good after the treatment. There were no the symptoms of dizziness, headache and the attack of the disease. His tongue coating was scant. His tongue was red. There were small rashes all over the body. Professor Zhang suggested him to take MRI test after one month treatment. The prescription was changed as follows: baishao (white peony root), tianma (gastrodia root), etc. 4 dosages in total.

 

Date: May 14, 2009

The result of MRI examination of the head was as follows: 1. congenital cysts. 2. Topical internal carotid artery and arteriae vertebralis became thin. Professor Zhang thought it was due to poor blood circulation. The prescription was changed as follows: zhimu (anemarrhena root), taoren (peach kernel), etc. 5 dosages in total.

 

Date: May 19, 2009

His common condition was good. There were no symptoms of headache and dizziness. His diet, sleep, urine and bowel movement were normal. Continue to take the former prescription. 4 dosages in total.

 

Date: May 24, 2009

There were no symptoms of dizziness and headache after comprehensive treatment including herbal tea, acupuncture and massage. On Jan. 31, he had suffered from headache and the attack of epilepsy once. However, there was no such similar phenomenon in the recent four months. His other condition was good. The patient decided to leave the hospital with taking 2 months herbal tea back to home for continuous treatment. The prescription was changed as follows: honghua (carthamus flower), taoren (peach kernel), etc. 60 dosages in total.

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