Brief Summary:
Hagit, from Israel,
has received our treatments for 39 days for suffering from motor
neuron disease. By the doctors’ efforts, she has got obvious
improvement. Her treatment is successful.
Records of
Hospitalization
Name:
Hagit Birthplace: Israel
Sex:
Female
Occupation: Actress
Age:
24 Date of Admission: Nov.20, 2009
Nationality:
Jew Date of
Record: Nov.20, 2009
Marital Status:
Married Onset Season:
Beginning of summer
Complainer:
The patient herself.
First Medical Record
Date: Nov.20, 2009
Time: 10:00 a. m.
Hagit, a 24-year-old female, who has suffered from motor neuron
disease, was hospitalized in our hospital for comprehensive
treatment at 01:00 a.m. on Nov. 20, 2009.
Essentials for Diagnosis:
1. The
patient had had difficulty in walking for 6 months. Besides, she
had had
muscular dystrophy for 18 months.
2. Two
year ago, the patient began to have difficulty in bending her
fingers without obvious reason. Then she had muscular dystrophy
18 months ago. At last, she had difficulty in walking 6 months
ago. In July of 2009, she was diagnosed as
motor neuron disease by EMG in her local hospital. At the same
time, she was given Rilutek for her treatment. However, she did
not get a good result. At last, she decided to come to our
hospital to receive the comprehensive treatment on Nov. 20,
2009.
3. T 36.1℃,
P 72 times/minute, R 20 times/minute, BP 100/60mmHg.
4. She
grew normally with medium nutrition. Her mind is conscious. She
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 72 times/minute. Cardiac rhythm was
regular. No pathological murmurs on auscultation.
6. The
patient had obvious muscular dystrophy. There were cracks in the
middle of the tongue. Her pulse was slippery.
7. Accessory
examination: none.
Diagnostic Basis:
TCM: The patient had had muscular dystrophy for 18 months.
Besides, she had difficulty in walking for 6 months. The patient
felt weakness of the upper limbs. Her fingers also had
difficulty in doing exercise. For example, she could not write
by her hand. At the same time, her sleep was not good.
There were cracks in the middle of
the tongue. Her pulse was slippery. According to the symptoms of
the tongue and pulse, she was diagnosed as wilting pattern.
Western Medicine: The patient had had muscular dystrophy for 18
months. Besides, she had had difficulty in walking for 6 months.
The patient felt weakness of the upper limbs. Her fingers also
had difficulty in doing exercise. In July of 2009, she was
diagnosed as motor neuron disease by EMG.
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: The motor neuron disease should be
differentiated from syringomyelia. The syringomyelia can cause
the spinal swollen. The disease can be diagnosed clearly by the
examination of MRI.
First Diagnosis:
TCM diagnosis: Wilting pattern
Symptom identification: Spleen-qi vacuity and blood failing to
nourish the heart
Western Medicine
diagnosis: motor neuron disease
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. Food with high
protein.
5. TCM treatment
strategy: fortify the spleen and boost qi, nourish the blood and
quiet the 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: November 21,
2009 Time: 10: 00 a. m.
The patient had had muscular dystrophy for 18 months. Besides,
she had had difficulty in walking for 6 months. The patient felt
weakness of the upper limbs. Her fingers also had difficulty in
doing exercise. In July of 2009, she was diagnosed as motor
neuron disease by EMG in her local hospital.
She was diagnosed as wilting pattern
by TCM. Then according to her latest symptoms, our expert team
prepared a special formula for her for the first time.
Date: November 22,
2009 Time: 10: 00 a. m.
The feedback of the examination today was as follows: Blood R (－),
Urine R (－).
The function of the liver was normal as well as the kidneys.
Then we changed the formula a little for the first time.
Date: November 25,
2009 Time: 10: 00 a. m.
The patient said
that she felt more comfortable than before. And her sleep also
became better. Sometimes she had sweat on her eyebrow at night.
Date: November 30,
2009 Time: 10: 00 a. m.
Yesterday, the
patient had a cold. Her other conditions were in normal. Then we
changed her formula a little for the second time.
Date: December 5,
2009 Time: 10: 00 a. m.
The patient had
menstruation today. She felt lumbago and bellyache. She said
that she felt much better then before. Then according to her
latest condition, we changed her formula for the third time.
Date: December 10,
2009 Time: 10: 00 a. m.
The patient’s
menstruation ended. Her other conditions were normal. Then she
was told to use the formula of November 30.
Date: December 15,
2009 Time: 10: 00 a. m.
The patient said
that she had burning heat sensation of the stomach. Her other
conditions were good. Then we changed her formula for the fourth
time.
Date: December 20,
2009 Time: 10: 00 a. m.
The patient had a
cold yesterday. Then we changed the formula a little for her.
Date: December 25,
2009 Time: 10: 00 a. m.
The patient felt
that everything was OK. Her walking had improved a lot. Her
sleep was good. So she still used the same formula to
consolidate the result.
Date: November 27,
2009 Time: 10: 00 a. m.
The
patient decided to leave the hospital tomorrow.
