¡¡

Brief Summary: On Apr. 10, 2008, Grigorij, from Croatia, suffered from Parkinson¡¯s disease with the symptoms of weakness of the lower limbs and difficulty in walking as well as the trembling of all the limbs, was hospitalized in our hospital. After more than one-month TCM treatment, he has achieved much improvement in our hospital.    

 

Records of Hospitalization

Name: Grigorij                                                                                                   Sex: Male

Age: 47                                                                                                               Profession: Clerk

Nationality: Croatia                                                                                           Marital Status: Married

Onset Season: Spring                                                                                        Date of Admission: Apr. 10, 2008  

Complainer: The patient himself                                                                          Reliability: Reliable

 

First Medical Record

Apr. 10, 2008 

Grigorij, a 41-year-old male, has suffered from weakness of the lower limbs with difficulty in walking for four years, accompanied with trembling of all the limbs for more than one year. He was hospitalized in Huaihua Red Cross Hospital for further treatment at 20: 10 p.m. on Apr. 10, 2008.

 

Essentials for Diagnosis:

1. The patient has suffered from weakness of the lower limbs with difficulty in walking for four years, accompanied with trembling of all the limbs for more than one year.

2. At the end of 2003, the patient began to feel weakness of the lower limbs with difficulty in walking without any obvious causes. With his ability of balance decreasing, his condition aggravated progressively. A year ago, his right hand appeared weak and could not write normally. At the same time, there was slightly muscular trembling on all his limbs with the feeling of weakness all over the body. Then he went to a local hospital for a MRI examination. The results of the brain examination showed that there was damage in the cerebral lacuna, and he was diagnosed with Parkinson¡¯s disease. Since 2005, he accepted the western medicine treatment of motor nerves¡¯ reducing, but without obvious effect. To seek for a further comprehensive treatment, he was hospitalized in our hospital on Apr. 10, 2008.

3. T 36.3¡æ£¬P 82 beats/minute, R 20 times/minute, BP 130/80 mmHg, K 119 kg.

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

5. The flexibility of the upper limbs decreased, and there were obvious trembling when raising his upper limbs horizontally. The grip of his left hand was 62 kg, and that of his right hand was 65 kg. He suffered from weakness of the lower limbs, with difficulty in walking. The distance of his steps shortened with a decreasing balance. The experiment of raising the straight legs was normal. His tongue was pale with thin and white tongue coating. The pulse was string-like and thready.

6. No thoracic deformity. Chest percussion noted resonance. Sound of breath is bilaterally clear on auscultation. No sound of pleural friction.

7. Diagnostic examination: Not provided

 

Diagnostic Basis£º

TCM: The patient has suffered from weakness of the lower limbs with difficulty in walking for four years, accompanied with trembling of all the limbs for more than one year. His lower limbs were weak with a decreasing balance. His right hand was also lack of strength. Besides, there was slight trembling on the muscles of all his limbs. He felt fatigued all over the body. His tongue was pale with thin and white tongue coating. The pulse was string-like and thready. Due to dual vacuity of the liver and kidneys, deficiency of qi and the blood, and muscular malnutrition of all the limbs, then it gradually resulted in Tremor Syndrome. 

Western medicine: The patient has suffered from weakness of the lower limbs with difficulty in walking for four years, accompanied with trembling of all the limbs for more than one year. The movements of flexibility of his upper limbs have decreased, and there was obvious trembling when raising his upper limbs horizontally. His lower limbs were weak with difficulty in walking. The distance of his steps shortened with a decreasing balance. In 2005, he went to a local hospital for a MRI examination for the brain, and was diagnosed with Parkinson¡¯s disease.

 

Diagnostic Differentiation:

TCM (Traditional Chinese Medicine): The patient¡¯s Tremor syndrome should be differentiated from Flaccidity syndrome. Tremor syndrome is mainly characterized by shaking and trembling of the limbs, often accompanied with hypertonicity of the limbs and instability of the steps. Flaccidity syndrome is mainly characterized by limp, weak, and emaciated limbs with muscular atrophy. Generally speaking, there is no trembling phenomenon. They are not difficult to be distinguished in clinics.

WM (Western Medicine): Parkinson¡¯s disease should be differentiated from Parkinson degenerative disease. Parkinson degenerative disease is always accompanied with the symptoms of ataxia, nystagmus, difficulty in speaking, and mental retardation. The Babinski sign was (+). They are not difficult to be distinguished in clinics.

 

First Diagnosis: 

TCM diagnosis: Tremor Syndrome

Symptom diagnosis: Dual vacuity of liver and kidneys, accompanied with deficiency of qi and the blood.

WM diagnosis: Parkinson¡¯s disease

 

Plans for treatment strategy and nursing:

1. On routine care of traditional Chinese internal medicine.

2. On grade II care.

3. Under care of a companion.

4. Regular diet.

5. Herbal tea (to nourish and enrich the liver and kidneys, to boost qi and quicken the blood.): 6 dosages in total. One dosage a day and drink twice.

Main herbs used in the herbal tea: shudi (cooked rehmannia root), zaopi (cornus fruit), duzhong (eucommia bark), etc.

6. Acupuncture and massage: once a day.

7. Have more medical examinations if necessary.

 

Date: Apr. 13, 2008                               Time: 10:00 a.m.

The related examinations of the patient are as follows: the blood routine examination, the urine routine examination, the functional examination of liver and kidneys, and the examinations of the blood sugar and ECG were all normal. The patient still felt weakness of the lower limbs with difficulty in walking. The distance of his steps was short in panic gait, besides there was trembling of all the limbs. Both his diet and sleep were normal, so were his bowel movement and urination. His tongue body was slightly dark with thin tongue coating. His pulse was small and string-like. The symptoms belong to the deficiency of the liver and kidneys, liver wind entering the network channels. The TCM treatment strategy is to enrich and supplement the liver and kidneys, to extinguish the wind and free the network channels. According to the above information, the doctor advised him to continue to take herbal tea of the former prescription.

 

Date: Apr. 17, 2008                               Time: 10:00 a.m.

The patient said that the trembling of his double hands has lessened, but the other symptoms remained as before. His tongue and pulse were the same as before. The doctor advised him to take the former herbal tea except chaenomeles fruit and carthamus flower and add pueraria root, etc. into the former prescription.

 

Date: Apr. 21, 2008                               Time: 10:00 a.m.

On Apr. 18^th, the patient had an examination of magnetic resonance to the part of head and neck in No. 2 Hospital of Huaihua. He was further diagnosed with Parkinson¡¯s disease. After 10-day¡¯s comprehensive treatment, the trembling of his double hands lessened, and the distance of his steps increased. Besides, his steps were more stable than before. His sleep also got some improvement. His food intake was normal, so were the bowel movement and urination. His tongue was dark with white and thin tongue coating. His pulse was thready and string-like. The TCM treatment strategy was to enrich yin and extinguish wind, to boost qi and free the network channels.

 

Date: Apr. 24, 2008                               Time: 10:00 a.m.

In today¡¯s examination, his symptoms were the same as before. There was no significant improvement after the TCM treatment. His sprit, food intake and sleep were the same as usual. Both the bowel movement and urination were normal. His tongue body was slightly thin in dark red with thin tongue coating. His pulse was thready and string-like. He will continue to follow the same TCM treatment.

 

Date: Apr. 27, 2008                               Time: 10:00 a.m.

After half-month comprehensive treatment of herbal tea, acupuncture and massage, the trembling of his double hands was lessened day by day. The trembling of the lower limbs also got some improvement. The distance of his steps increased, and the steps were more stable than before. Besides, his sprit, diet and sleep were all normal, so were the bowel movement and urination. His tongue body was slightly thin in dark red with thin tongue coating. His pulse was thready and string-like. He will continue to follow the same TCM treatment.

 

Date: May 1, 2008                               Time: 10:00 a.m.

After 20-day comprehensive treatment, not only the trembling of all the limbs but also the instability of walking has achieved obvious improvement. He was pleased with his quiet sleep. But the patient still suffered from the dysfunction outside the vertebral system, which is an intractable disease. According to the thin and small tongue, as well as his small, slow and weak pulse, TCM identifies it as the dual vacuity of liver and kidneys, so the TCM treatment strategy is to enrich and supplement the liver and kidneys, to extinguish wind and free the network channels.

 

Date: May 6, 2008                               Time: 10:00 a.m.

After four-week comprehensive treatment of herbal tea, acupuncture and massage, the trembling of all his limbs was lessened a lot. The distance of his steps increased, and the panic steps disappeared. The balance function has achieved great improvement. His sleep was sound. Besides, his spirit and food intake were both normal, so were the bowel movement and urination. His tongue body was thin with thin tongue coating. His pulse was string-like and moderate. He would continue to take another five dosages of herbal tea.   

 

Date: May 11, 2008                               Time: 10:00 a.m.

After one-month comprehensive treatment, the trembling of all his limbs was lessened a half. His sleep, spirit and food intake were all normal. He could walk as a normal person. His tongue body was fatter than before in slightly dark. His pulse was string-like and moderate. The TCM treatment strategy is also to enrich and supplement the liver and kidneys, extinguish wind and free the network channels.

 

Date: May 16, 2008                               Time: 10:00 a.m.

All the symptoms are progressing day by day. His spirit, food intake and sleep were the same as usual. The bowel movement and urination were both normal. The tongue body was slightly dark with thin tongue coating. The pulse was string-like and moderate. He would keep the same prescription.

 

Date: May 20, 2008                               Time: 10:00 a.m.

Today, the patient demanded to leave the hospital. He was approved of leaving the hospital tomorrow.

¡¡

¡¡