Brief Summary:
On September 24, 2010, Zahra, from Iran, who has suffered from
flaccidity disease and hysteromyoma was hospitalized in our
hospital. She has had the problem of speaking and movement of
her limbs for 22 years. After nearly two months treatment, she
achieved a good result.
Record of
Hospitalization
Name:
Zahra
Birthplace: Iran
Sex:
Female
Profession: Student
Age:
23 Date
of Admission: September 24, 2010
Marital Status:
Unmarried Date of Record:
September 24, 2010
Nationality:
Iran Onset Season:
Autumnal Equinox
Complainer:
The patient
herself
Major Complaints:
She has had the problem of speaking and movement of her limbs
for 22 years.
Present Illness:
Due to dystocia, the patient's mother had the cerebral hypoxia.
When patient grew to 4 years old, her father found that she
could not speak fluently and walk
steadily.
When she walked, it was very easy for her to fall down. Then,
her parents took her to hospital. MRI showed that her brain was
damaged. The diagnosis was sequelae of cerebral palsy. The
patient didn't take any medication just had rest at home. When
patient get older and older, her condition became worse and
worse. During May to July of this year, the patient got better
after taking the herbal tea which we posted to her. Now, the
patient has the problem of speaking and movement of her limbs
and general weak body. Sometimes, when she raised her upper
limbs, her hands will shake. Because of loss of power, she can
not hold the pen when she writes things, and her hands will
shake. Also, she has the problem of near sighted, dry mouth, but
she has good spirit and appetite.
Disease History: In
2007, the patient found that she had fibroid, but she didn't
take any medication.
She is not allergic to any food or medicine. She has no history
of blood transfusion or operation .
Personal History: She was born in Iran and
never gone to any foreign country. She lives in dry environment,
likes any meat food and fried food.
Marriage History: She was unmarried.
Menstrual History: She had her first
menstruation at her 15 years age. She has dysmenorrhea, and the
volume of her menstruation is a little bit much than normal and
accompany with blood spot.
Family History: No family members got the
similar disease before.
Physical Examination
T: 36.3≧
P: 77bpm R: 20bpm BP: 98/60mmHg
She was mid-nourished and normally developed.
Her mild was clear. Her skin was moist. Her neck was soft and
trachea
is in the middle.
No superficial lymph-node enlargement. No enlarged thyroid.
Sound of breath was bilaterally normal on auscultation. Heart
border was normal. Heart beat 77/min. Cardiac rhythm was
regular. No pathological murmurs on auscultation. Abdomen was
flat and soft without tenderness or rebound tenderness. The
liver and spleen were not palpable. No deformity, but, sometimes
when
she raised her upper limbs, her hands will shake. Because of her
weak body, she can not hold a pen when she writes things, and
her hands will shake. She can not walk steadily. Also,
She has slightly pale tongue body and thick tongue coating and
weak pulse.
First Diagnosis:
Assistant Examination: 1. MRI: Damaged Brain
2.
B ultrasonic: Womb Fibroid
TCM diagnosis: Wei-syndrome (flaccidity
syndrome) Zheng-syndrome (fibroid)
Symptom Diagnosis: marrow sea deficiency,
deficiency of blood and Qi
Western medicine diagnosis:
sequelae of cerebral palsy, fibroid
Diagnosis Basis: TCM: The
patient
had had the problem of speaking and movement of her limbs for 22
years. TCM believed that congenital dystrophy, the loss of
kidney essence and marrow sea can cause these problems. Also,
She has slightly pale tongue body and thick tongue coating and
weak pulse. Western medicine: 1. She
had the cerebral
hypoxia when she was born 2. She can not speak fluently and walk
steadily and general
weak. 3.
Sometimes, when she
raised her upper limbs, her hands will shake. Because of loss of
power, she can not hold a pen when she writes things, and her
hands will shake. 4.
MRI: Damaged Brain
Plan of treatment and care
1. On routine
care of traditional Chinese internal medicine
2. On grade Two
care
3. Under care of
a companion
4. Low-fat
protein diet
5.
Therapeutic Principle: Reinforcing kidneys, strengthening brain;
nourishing Qi and blood
6. Herbal
tea: One dosage a day and drink twice, each time 180ml
7.
Acupuncture and massage: Once a day
8. Have
more medical examinations if necessary
Date: September 25,
2010 Time: 10:00 a.m.
Due to dystocia,
the patient's mother had the cerebral hypoxia. When patient grew
to 4 years old, her father found that she could not speak
fluently and walk
steadily.
When she walked, it was very easy for her to fall down. Then,
her parents took her to hospital. MRI showed that her brain was
damaged. The diagnosis was sequelae of cerebral palsy. The
patient didn't take any medication just had rest at home. In
2007, the patient found that she had fibroid, but she didn't
take any medication. Now, the patient's condition became worse
and worse. Her illness is the problem of speaking and movement
of the four limbs and fatigued body. Sometimes
when
she raised her upper limbs, her hands will shake. Because of her
weak body, she can not hold a pen when she writes things, and
her hands will shake. Also,
She has slightly tongue body and thick tongue coating and weak
pulse. So, Professor Zhang diagnosed her with Wei-syndrome
(flaccidity syndrome) and Mass-syndrome (fibroid).
Date: September 26, 2010
Time: 10:00 a.m.
We got the results of the patient's body
check. It was: Hb= 106g/l
Date: September 27,
2010 Time: 10:00 a.m.
The patient has no
obvious change of her body. Yesterday, she has clear
menstruation.
Date: September 30, 2010
Time: 10:00 a.m.
The patient gained
more power of her body.
Date: October 6, 2010
Time: 10:00 a.m.
The power of the
four limbs was increased. And the situation of her writing and
walking got better.
Date: October 11, 2010
Time: 10:00 a.m.
At October 8, the
patient did MRI on her head, but the result showed no obvious
problem.
Date: October 16, 2010
Time: 10:00 a.m.
The movement of her
four limbs is much better than before, and the power of her four
limbs is increased. She is getting better about her walking.
There were no pains on her abdomen and menstruation ended.
Date: October 21, 2010
Time: 10:00 a.m.
The patient is in a
stable situation.
Date: October 26, 2010
Time: 10:00 a.m.
The patient has
good spirit, appetite and sleep.
Date: October 30, 2010
Time: 10:00 a.m.
The patient has
good spirit. The movement of her four limbs is much better than
before, and the power of her four limbs is increased. Also, the
balance of her walking is improved greatly. The patient has
urinary incontinence, and we are waiting for the result of her
liver and kidneys and urine test.
Date: November 4, 2010
Time: 10:00 a.m.
The urine test
shows that it is normal. The urinary incontinence is improved
during recent days. At the most time, she can control her
urination. When she lies down on the bed, she will feel pains on
her abdomen.
Date: November 9, 2010
Time: 10:00 a.m.
The patient gets a
big improvement of her urinary incontinence. She can move her
figures more freely. Also, her writing is getting better. The
balance of her walking is improved. And she
coughs up clear phlegm. But,
the fluent speaking is still a problem.
Date: November 13,
2010 Time: 10:00 a.m.
The patient's
menstruation is normal and the menstrual period is 7 to 10 days.
The urinary incontinence is not a problem for patient anymore.
The whole situation of her is getting better.
Date: November 18, 2010
Time: 10:00 a.m.
The movement of her
limbs is improved. No shaking and blurred speaking. She has
normal spirit, sleep and appetite. The volume of her
menstruation is less and the menstrual period is 6 to 7 days.
Date: November 23, 2010
Time: 10:00 a.m.
The whole situation
of patient is getting better.
Date: November 26, 2010
Time: 10:00 a.m.
The problem of her
urinary incontinence is recovered completely.
Date: November 30, 2010
Time: 10:00 a.m.
The movement of her
limbs is improved further. She can move her figures more freely.
Also, her writing is getting better. The balance of her walking
is improved. She has normal spirit, sleep and appetite.
Date: December 4, 2010
Time: 10:00 a.m.
The patient is in a
low mood during recent days. She has no obvious continuous
improvement and just in a stable condition.
Date: December 7, 2010
Time: 10:00 a.m.
Today, the patient is going to leave.
