First Medical Record
Date: Aug. 24, 2008 Time: 19:00 p.m.
Iancu, a 40-year
old male, has suffered from stiffness and weakness of all the limbs for
9 years.He was hospitalized in our hospital for TCM treatment at 19:00 p.m.
on
Aug. 24, 2008.
Essentials for Diagnosis:
1. The patient has suffered from stiffness and weakness of all the limbs for 9 years.
2. Nine years ago, the patient began to suffer from stiffness and weakness of all
the
limbs without any obvious reasons, and his condition was gradually aggravated.
Then
he went
to a local hospital for a diagnosis, and was diagnosed with MS after
an examination of MRI.
He had ever taken many kinds of western medicines, bu
there was no obvious improvement. His present symptoms were follows: weakness
of
all
the
limbs; stiffness of the hands and legs with normal movement of flexion
and extension; pains of the joints
all over the body; poor balance of the lower
limbs and unable to walk alone; constipation
for 4 to 5 times a day; frequent
urination with a phenomenon
of urinary incontinence; sound sleep; poor food
intake; blurred vision; slightly atrophic
muscles; swollen throat; red tongue
with
thin, yellow and slightly thick-slimy tongue coating; string-like, slippery and weak
pulse.
3. T 36.3℃，P 76 beats/minute, R 20 times/minute, BP 110/70 mmHg.
4. He grew normally with common nourishment. His mind was clear. He had an expression of chronic illness and languidness. His body was in a positive posture
and he was cooperative in examination.
5. No thoracic deformity. Chest percussion noted resonance. Sound of breath is bilaterally clear on auscultation. No sound of pleural friction. Heart border was
normal. Heart beat was76 times/minute. Cardiac rhythm was regular. No pathological murmurs
on auscultation.
6. The muscles all over the body were slightly atrophic. The muscular strength of
the
both hands was Grade Ⅳ+. The gripping power of the left hand was 30.6 kg,
and that
of
the right hand was 32.2 kg. The muscular strength of his lower limbs was Grade Ⅳ+.
The flexion and extension of the joints were normal.
7. Diagnostic examination: The MRI shows MS.
Diagnostic Basis:
TCM: The patient has suffered from stiffness and weakness of all the limbs for
9 years.His present symptoms were follows: weakness of all the limbs;
stiffness of
the hands
and legs with normal movement of flexion and extension; pains of the joints all over thebody; poor balance of the lower limbs and unable to walk
alone; constipation for 4 to 5 times a day; frequent urination with a phenomenon of urinary incontinence; sound sleep; poor food intake; blurred vision; slightly
atrophic muscles; swollen throat; red tongue with thin, yellow and slightly thick-slimy tongue coating; stringlike, slippery and weak pulse. According to the
symptoms of his tongue and pulse, it is shown that due to damp-heat evil obstructing the channels, then the skin and the
muscles of the sinew
and bone will lose the nutrition, which causes the decreasing of the
function.
So it is believed as wilting.
Western Medicine: The patient has suffered from
stiffness and weakness of all the limbs
for 9 years. The muscles all over the body were slightly atrophic. The muscular strength of the both hands was
Grade Ⅳ+. The gripping power of the left hand was 30.6 kg, and that of the right hand was 32.2 kg. The muscular strength of his lower limbs was Grade
Ⅳ+. The flexion and extension of the joints were normal. The MRI examination showed MS.
Diagnostic Differentiation:
TCM: The patient’s wilting syndrome should be differentiated from impediment
syndrome. Wilting syndrome is characterized by limp, weak, and emaciated limbs
with muscular atrophy. A patient suffered from wilting syndrome may even become
unable to hold anobject or to stand without any support. Besides, the patient’s
lower limbs are more often affected, though
he or she usually has no joint pains. On the contrary, impediment syndrome is generally characterized by 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 (MG), which is an acquired autoimmune
disease with the transferring obstacles owing to the reduced
acetylcholine receptor
in the site of neuromuscular junction. It can occur at any
age and there
are about 60 percent people stricken before 30 years old. Women are more often affected than men are. The most obvious characteristic of MG is rapid
fatigability of the skeletal muscles
affected, improved with rest or medicines that inhibits
the activity of cholinesterase. It can involve
cardiac muscle and smooth muscle.
MG
patients of different ages often have different clinical manifestations and
courses, which
are different from those of flaccidity syndrome patients.
First Diagnosis:
TCM diagnosis: Wilting syndrome
Symptom identification: Damp-heat obstructing the channels.
Western medicine diagnosis: Multiple Sclerosis (MS)
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. Low-fat diet.
5. Herbal tea (to clear heat and dispel dampness, sooth the sinews and quicken
the channels): one dosage a day and drink twice.
Main herbs used in the herbal tea: huangqi (astragalus root), chuanqiong (dipsacus
root), cangshu (atractylodes root), etc.
6. Acupuncture and massage: once a day.
7. Strengthen the functional exercise of all the limbs.
8. Have more medical examinations if necessary.
Date: Aug. 25, 2008 Time: 10:00 a.m.
The patient has suffered from stiffness and weakness of all the limbs for 9 years.His present symptoms were as follows: the lower limbs with
difficulty in walking;
poor balance; pains of the joints all
over the body; blurred vision; frequent and
urgent urination;
constipation; swollen throat; red tongue with slightly yellow and
thick-slimy tongue coating; string-like, slippery and weak pulse. The
western
medicine diagnosed it with MS (Multiple Sclerosis)
The TCM treatment diagnosed
it with wilting. The symptoms belong to damp-heat obstructing
the channels. The TCM strategy is to clear heat and dispel dampness, sooth the sinews and
quicken
the channels. The prescription was as follow: huangqi (astragalus root), chuanqiong (dipsacus root), cangshu (atractylodes root), etc. 4 dosages in total.
Date: Aug. 26, 2008 Time: 14:00 p.m.
All the limbs were stiff and weak with paroxysmal tremor, especially serious in the lower
limbs. He had difficulty in walking with spastic gaits, and was unable to
walk
alone. In the three routine examinations as well as examinations of the liver and kidneys’ functions, blood sugar, E4A, it is shown that the calcium content
is a little low, and
the other results were normal.
Date: Aug. 28, 2008 Time: 10:00 a.m.
The difficulty in walking with spastic gaits got some improvement.He could walk more
steadily than before. The swollen throat has disappeared. The pressing pains in the
right lower abdomen lessenedwithout obvious rebounding tenderness. The doctor
changed the prescription a little. Five dosages in total.
Date: Sept. 2, 2008 Time: 9:00 a.m.
The difficulty in walking improved obviously. The pains of the
joints all over the body and the right lower abdomen lessened. Now, he felt shoulder pains. Then the
prescription was changed again. Five dosages in total.
Date: Sept. 7, 2008 Time: 9:00 a.m.
The pains of the joints all over the body improved. The abdominal distension has disappeared. The bowel movement became normal. The pressing pains in the
lower abdomen also disappeared. The prescription was changed as follows: taoren (peach kernel), jixueteng (millettia root and stem), yizhiren
(bitter cardamon), etc. Five dosages in total.
Date: Sept. 12, 2008 Time: 9:00 a.m.
The patient still had the symptoms of frequent and urgent urination or incontinence.
In the recent days, he again had the phenomena of abdominal distension, pressing
pains and constipation. Considering it is related to the diet. His sleep was
poor.
The prescription was changed again. 5 dosages in total.
Date: Sept. 17, 2008 Time: 9:00 a.m.
The stiffness and weakness of the lower limbs and the difficulty
in walking got some improvement. The steps became much more steadier than before. He still had
the
symptoms of constipation,
incontinence and frequent urination. Once in a while, he
had bed-wetting phenomena. The prescription was changed again. 5 dosages in total.
Date: Sept. 22, 2008 Time: 9:00 a.m.
The symptom of frequent and urgent uriantion improved. These days,
he has no phenomenon of bed-wetting. The constipation also improved. No symptoms of
abdominal
distension or abdominal pains. The stiffness of the lower limbs improved
but still weak. The limbs would lose balance when he
was walking. The tongue was
red with cracks in the middle. The
tongue coating was slightly slimy. His food intake was poor. The prescription was as follows: chuanqiong (ligusticum root),
danpi (moutan root bark), gouqi (lycium berry), etc. 5 dosages in total.
Date: Sept. 28, 2008 Time: 9:00 a.m.
The stiffness and the weakness of all the limbs improved
significantly, so did the difficulty in walking along with poor balance. He sometimes could walk alone
as
far as 300 m in steady gaits. The food intake and sleep became normal.
He said
that his shoulders were painful, and he would get an examination of the spine.
Since today he drank too much soft drinks, the amount of the urine increased,
occasionally
with incontinence. The tongue was red with cracks in the middle.
The tongue coating was thin and white. The pulse was string-like. The former prescription was changed a little. 5 dosages in total.
Date: Oct. 2, 2008 Time: 9:00 a.m.
He kept a steady condition. The prescription was kept the same. 5 dosages
in total.
Date: Oct. 7, 2008 Time: 9:00 a.m.
The days, the patient has suffered from red rash on the back
The pains of the
joints all over the body was related to the changement of the weather. The
strength of all the limbs increased a lot. His other condition was normal. The prescription was changed a little agiain. 5 dosages in total.
Date: Oct. 12, 2008 Time: 9:00 a.m.
His red rash on the back has disppeared. The pains of the joints all over
the
body improved obviously. The prescription was again changed a little. 5 dosages
in total.
Date: Oct. 17, 2008 Time: 9:00 a.m.
The pains of the joints all over the body has disappeared. The stiffness and weakness
of all the limbs as well as the poor balance got further improved, so did the frequent
and
urgent urination along with the constipation. These days, he had no phenomenon of incontinenece. He kept normal food intake, a sound sleep and a pleasant
mood.
The prescription was kept the same. 3 dosages in total.
