¡¡

Brief Summary: July 14, 2009, Samson from Pakistan, a 7-year-old boy, was hospitalized in our hospital due to suffering from metachromatic leukodystrophy (MLD), severe malnutrition and pneumonia. The boy had dysplasia for 5 years and his condition worsened with severe malnutrition for the recent 2 years. After 67 days treatment in our hospital, the boy got obvious improvement. The walking condition became much better. The patient himself could walk about 200 to 300 meters. His reaction became quicker than before and his weight also increased 3 kg.

¡¡

Records of Hospitalization

Name: Samson                                                                                                    Birthplace: Pakistan

Sex: Male                                                                                                            Age: 7                                  

Nationality: Pakistanis                                                                                         Date of Admission: July 14, 2009

Marital Status: Unmarried                                                                                  Date of Record: July 14, 2009

Complainer: The patient¡¯s father                                                                          Onset Season: Moderate Heat

The case was recorded by TCM group

¡¡

                                                                               First Medical Record

Date: July 14, 2009                                                    Time: 19: 00 p. m.

Samson from Pakistan, a 7-year-old boy, was hospitalized in our hospital due to suffering from metachromatic leukodystrophy (MLD). Besides, the boy had dysplasia for 5 years and his condition worsened with severe malnutrition for the recent 2 years. He was hospitalized in our hospital for treatment at 19:00 p.m. on July 14, 2009.

Essentials for Diagnosis:

1. The boy had dysplasia for 5 years and his condition worsened with severe malnutrition for the recent 2 years.

2. The patient began to grow slowly without obvious reason in July, 2004 and his parents did not pay much attention on it. Then his condition worsened day by day. In September of 2004, he was examined by a local hospital (name unknown) and diagnosed as myodystrophy. He was given a kind of western medicine for oral taking. However, he did not get much improvement after one month. In the recent two years, the condition became worse. His growth stopped. He was paralyzed and could not move by himself. His limbs were cold and had a slow reaction. Then he was examined by MRI at the local hospital (name unknown) and diagnosed as MLD. At the same time, the doctor told him that there was no method for his recovery. To pursue improvement, he came to our hospital for the treatment on July 14, 2009.

3. T 36.3¡æ, P 92 times/minute.

4. His growth stopped and had severe malnutrition. His mind was not very clear. He looked tired with a feeling of chronic illness.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 92 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The patient¡¯s muscles had been completely atrophied. He got paralysis and could not move by himself. Besides, he had difficulty in breathing and his limbs were cold.  

7. Accessory examination: none.

Diagnostic Basis:

TCM: The patient¡¯s had dysplasia for 5 years and his condition worsened with severe malnutrition for the recent 2 years. His muscles had been completely atrophied and he could not move by himself. The patient¡¯s limbs were cold and his reaction was slow.

Besides, he had difficulty in breathing and his mind was not clear. The tongue body was thin. The tongue coating was yellowish and thin. His pulse was slippery. According to the symptoms of the tongue and pulse, he was diagnosed as wilting pattern.

Western Medicine: The patient¡¯s had dysplasia for 5 years and his condition worsened with severe malnutrition for the recent 2 years. His muscles had been completely atrophied and he could not move by himself. The patient¡¯s limbs were cold and he had a slow reaction. Besides, he had difficulty in breathing and his mind was not clear. In 2007, he was diagnosed with MLD by MRI examination.  

Diagnostic Differentiation:

TCM: The patient's wilting pattern should be differentiated from impediment pattern. Wilting pattern is mainly characterized by limp, emaciated sinews and bones, with weakness of the muscles. However, impediment pattern is generally characterized by joint pains. So they are not difficult to be distinguished.

Western Medicine: MLD should be differentiated from Alexander disease. Alexander disease appears at an earlier time, usually when the patient is a baby. The patient has a big head. The intelligence regresses gradually. There are spasms and epilepsy with the patient. Some cases could be seen on the children or adults. There are white substances in a diffuse and lower density in the forehead with the help of CT examination. So they are not difficult to be distinguished.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Wilting pattern

Symptom identification: dual vacuity of qi and yin.

Western Medicine: Metachromatic Leukodystrophy (MLD), severe malnutrition, pneumonia.

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. Liquid food.

5. TCM treatment strategy: boost qi and nourish yin, improve the original spirit.

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

7. Acupuncture and massage: once a day.

8. Have more medical examinations if necessary.

¡¡

Date: July 17, 2009                                                     Time: 10: 00 a. m.

The patient had dysplasia for 5 years and his condition worsened with severe malnutrition for the recent 2 years. His muscles had been completely atrophied and he could not move by himself. The patient¡¯s limbs were cold and he had a slow reaction. The tongue body was thin and slightly reddish. His tongue coating was yellowish and thin. According to the symptoms of the tongue and pulse, he was diagnosed with wilting pattern. Symptom identification: dual vacuity of qi and yin. TCM treatment strategy: boost qi and nourish yin and impprove the original spirit.

 

Date: July 18, 2009                                 Time: 10:00 a. m.

The patient¡¯s cardiac rate and breath were stable. However, his mind was still not very clear and did not have bowel movement. The tongue body was thin. The tongue coating was yellowish and thin. His pulse was slippery. According to his latest symptoms, our experts prescribed a special formula for him to boost qi and nourish yin, improve the original spirit. At the same time, we would continue to observe his condition closely.

 

Date: July 19, 2009                                 Time: 10:00 a. m.

The patient had no obvious improvement on consciousness and still had a slow reaction. The breath was stable. His stool and urine became normal. He ate a little more food compared to the day before yesterday. The tongue body was thin. The tongue coating was yellowish and thin. His pulse was slippery. We continued to observe his condition closely.

 

Date: July 20, 2009                                 Time: 10:00 a. m.

The patient¡¯s condition was similar to that of yesterday. He had taken milk 300ml, one egg, one apple and a piece of bread yesterday. The time of spasms reduced. The breath was still stable. The cardiac rate was 78 times/minute. His health condition seemed to become better. However, we still need to observe closely.

 

Date: July 21, 2009                                 Time: 10:00 a. m.

The patient did not have fever for recent few days. The spasms had reduced. The breath was still stable and the cardiac rate was in the normal range. His mind was still not very clear and he still had a slow reaction. The tongue body was thin. The tongue coating was yellowish and thin. His pulse was slippery. So based upon his latest symptoms, our experts changed his formula a little to help him well.

 

Date: July 24, 2009                                 Time: 10:00 a. m.

The patient had not had fever for 6 days. The breath was stable and the cardiac rate was normal. His mind was still not very clear and he still had a slow reaction. Take the same formula and 3 dosages per day.

 

Date: July 30, 2009                                 Time: 10:00 a. m.

The patient did not have fever until now. The spasms had got obvious progress. His appetite became better. The tongue body was thin. The tongue coating was yellowish and thin. His pulse was slippery. Still use the same formula to consolidate the effect.

 

Date: Aug. 4, 2009                                 Time: 10:00 a. m.

The patient did not have fever for 10 days. And the time of spasms reduced obviously. He could eat more food than before and his weight had increased 2 kg. However his mind was still not very clear. Then our experts changed the formula a little and added some other kind of herbs to his formula.

 

Date: Aug. 7, 2009                                 Time: 10:00 a. m.

The patient¡¯s temperature was normal. The breath was stable and his appetite was good. His reaction was more flexible than before. The tongue coating was yellowish and thin. His pulse was slippery. Then our experts changed his formula a little according to his latest symptoms.

 

Date: Aug. 11, 2009                                 Time: 10:00 a. m.

After 41 days treatment, the patient¡¯s spasms had stopped. His appetite became normal and his weight also increased 2 kg. His mother told us that, the night before yesterday, he cried for the first time during his life. And the sound was big. From then on, his mother could hear his moan from time to time. Although, his mind was still not very clear. According to his latest condition, he took the same formula 6 dosages per day.

 

Date: Aug. 16, 2009                                 Time: 10:00 a. m.

The patient¡¯s mind was still not very clear and had a slow reaction. His other aspects had got much progress. Based on the former formula, we added another kind of herb shan yao to his formula. 5 dosages per day.

 

Date: Aug. 21, 2009                                 Time: 10:00 a. m.

The patient¡¯s expression became more multiple than before. The appetite and sleep were all is good condition. The patient¡¯s mind was still not very clear.

 

Date: Aug. 26, 2009                                 Time: 10:00 a. m.

The patient¡¯s condition was stable. His weight had increased 2.5 kg than the time he came to our hospital. His eyes¡¯ movement was flexible than before. However, his mind was still not clear. He continued to take the previous formula. 5 dosages per day.

 

Date: Sep. 1, 2009                                 Time: 10:00 a. m.

The patient¡¯s condition was stable. His spirit, appetite, urine and stool were in the normal condition. He did not have fever. He only had spasms once in a while. According to his latest symptoms, our expert changed his formula a little to enrich yin and extinguish wind.

Date: Sep. 6, 2009                                 Time: 10:00 a. m.

The patient¡¯s spasms became better. The time of spasms reduced. His other conditions were still stable. At this moment, the swallowing was still a little bit difficult for him. However, if it is the liquid food, the condition was better. Then our experts gave him a new formula based upon his condition to supplement the spleen, boost the lungs and downbear the qi.

 

Date: Sep. 11, 2009                                 Time: 10:00 a. m.

After taking our new formula, the patient's swallowing condition became better. However, it seemed that the condition of spasms worsened a little bit. According to his new symptoms, our experts changed the formula again to extinguish wind and open stasis. 

 

Date: Sep. 15, 2009                                 Time: 10:00 a. m.

The patient¡¯s swallowing condition had got obvious progress. The spasms condition also got much improvement. His other condition also got progress stet by step. Then his formula was the same. 3 dosages per day.

 

Date: Sep. 18, 2009                                 Time: 10:00 a. m.

The patient had got much improvement after 67 days treatment in our hospital. His mother decided to leave the hospital by taking 2 months herbal tea back to home for continuous treatment

¡¡