Brief
Summary:
On October 1, 2010,
Sarfaraz, from Iran, who had been suffering from unstable gait
for 3 years, developed into standing instability and walking
difficulty for 1 year, was hospitalized in our hospital. He
achieved some great improvement after more than one month¡¯s TCM
treatment.
Record of
Hospitalization
Name:
Sarfaraz Sex: Male
Age:
19 Marital
Status: Unmarried
Nationality:
Iranian
Date of Admission: Oct. 1,
2010
Companion:
His parents
First Medical Record
Date:
Oct. 2, 2010 Time: 9:30 am
This 19-year-old boy had
been suffering from unstable gait for 3 years, developed into
standing instability and walking difficulty for 1 year. The
patient was hospitalized in our hospital for TCM treatment at
2:00 pm on October 1, 2010.
Essential for Diagnosis:
1. The patient had been
suffering from unstable gait for 3 years, developed into
standing instability and walking difficulty for 1 year
2. Three years ago, the
patient got unstable gait and clumsiness over his whole general
body without any evident cause and then, he suffered staggering
gait, standing instability and unbalanced body. He developed
into limb dysmetria, volitional tremor, clumsy hands, and weak
muscles, especially the weak muscles of the lower limbs. He also
had unclear speech. He almost lost the functions of walking and
standing.
3. When the patient came
to our hospital, he had skinny and weak body, without obvious
muscle atrophy. The patient also suffered muscle pains and
stiffness over his neck muscles. He had no problem to drink. He
could eat foods by himself, but he was easy to be fatigued. He
lost the functions of walking and standing with weak lower
limbs. He at the same time had unclear speech, limb dysmetria
and nystagmus. Examination on his fingers, nose, knees and shin
was positive. His shallow sensory was abnormal. His sweating was
also abnormal with much head sweating. He had difficulties in
swallowing and urination. Stiffness was not so evident after
getting up from bed within half an hour. His muscles would be
softer after hot water shower. He had bowel movement once a day.
The color of his urine was slightly yellow.
4. T: 36.4¡ãC R: 20
times/minute P: 60 times/minute BP: 100/70mmHg
5. The patient was
stunted with skinny body. His spiritual activity was normal. He
had passive body position with stiff muscles.
6. The size and
formation of his thorax were normal. No enlargement with his
heart. Rhythm of his heart was 60 times per minute. Heart rate
was regular with no murmurs. Sound of
breathing in the lungs was clear, without any rhonchi.
7. He had
difficulty to raise his limbs and restriction of motion. His
spinal cord was scoliosis with restricted movement. His tongue
was red with thin and greasy tongue coating. His pulse was weak.
8. EKG
examination showed that he might suffer
right ventricular
hypertrophy.
Diagnostic Basis:
TCM:
The patient had suffered from stiff limbs, standing instability,
unbalanced body, limb dysmetria, nystagmus, weak muscles,
unclear speech, cold four limbs as well as volitional tremor.
The gripping power of his right hand was 13.9kg and left hand
12kg. His tongue was red with thin and greasy tongue coating.
His pulse was weak. Therefore, his conditions could be diagnosed
as ¡°Bone Shaking¡± in accordance with the concept of TCM.
Western Medicine:
He had been suffering from unstable gait for 3 years, developed
into standing instability and walking difficulty for 1 year.
Examination on his fingers, nose, knees and shin was positive. A
month ago, he took the MRI examination, which showed atrophy
over his brain. His parents were intermarriage. So, it was easy
to diagnose his case as hereditary ataxia.
Diagnostic
Differentiation:
TCM:
The patient¡¯s condition is usually differentiated from stroke.
Stroke has the main symptoms of sudden faint without any
consciousness or develops into paralysis of half of one¡¯s body
and twisted tongue and mouth. So, it is easy to differentiate
them.
Western Medicine
diagnosis:
Her condition should be differentiated with intracranial tumors.
The report of MRI showed there was atrophy of his brain.
Therefore, there is no difficulty to differentiate them.
First Diagnosis:
TCM: Bone shaking.
Symptom identification:
the deficiency of kidneys and wilting for the bones.
Western
medicine diagnosis: hereditary ataxia.
Treatment
strategy and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade¢ñcare.
3. Diet of high protein.
4. Pathogenesis: the
deficiency of kidneys and wilting of the bones.
5. TCM strategy: to
tonify the kidney essence and to promote the marrow for filling
the brain.
6. Herbal tea: one
dosage a day and drink twice
7. Acupuncture and
massage: once a day
8. Have more medical
examination if necessary.
Date: Oct. 3,
2010 Time: 10:00 am
Three years ago, the
patient got unstable gait and clumsiness over his whole general
body without any evident cause and then, he suffered staggering
gait, standing instability and unbalanced body. He developed
limb dysmetria, volitional tremor, clumsy hands, and weak
muscles, lower limbs in particular. He also had unclear speech.
He almost lost the functions of walking and standing. The
patient also suffered muscle pains and stiffness over his neck
muscles. He had no problem to drink. He could eat foods by
himself, but he was easy to be fatigued. He lost the functions
of walking and standing with weak lower limbs. He at the same
time had unclear speech, limb dysmetria and nystagmus. His
shallow sensory was abnormal. His sweating was also abnormal
with much head sweating. He had difficulties in swallowing. He
had too much saliva. His tongue was slightly red with thin and
greasy coating. His pulse was weak. His parents were of
intermarriage. According to the theory of TCM, his condition was
due to the deficiency of kidney essence and the loss of
nourishment of marrow. The treatment for his condition was to
tonify the kidney essence and to promote the marrow for filling
the brain.
Date: Oct. 6,
2010 Time: 10:00 am
The patient said his
urination problem was better, and he could control his urination
normally. Saliva was reduced. His speech was slightly clearer
than before. Strength of his two upper limbs was increasing. The
grasping power of his right hand was 20kg, while his left hand
was 17.9kg. Muscles were still stiff with clumsy body. His
tongue was slightly red with greasy tongue coating. His pulse
was weak.
Date: Oct. 9,
2010 Time: 9:30 am
Muscles
were still stiff with clumsy body. His tongue was slightly red
with greasy tongue coating. His pulse was weak. Muscle jumpings
were better.
Date:
Oct. 13, 2010 Time:
10:00 am
This morning, professor
Zhang and Dr. Zhu Ming paid a visit to the patient. His skin was
slightly warmer. He was easy to open his eyes. Muscles were
softer than before. His gripping power was increasing.
Date: Oct. 19,
2010 Time: 10:00 am
After near half a
month¡¯s treatment in our hospital, his spiritual activity and
facial complexion improved a lot. Nystagmus was basically
controlled. Muscles over his whole body were softer than before.
Sleep and appetite were normal. Urination and bowel movement
were normal. He could make a step more flexibly. His tongue was
slightly red with yellow tongue coating. His pulse was weak.
Date: Oct. 26,
2010 Time: 10:00 am
The patient¡¯s conditions
kept changing better. Now, he could walk by himself for 5 to 10
minutes. Muscles over his whole body were softer. His spirit was
high. His tongue was slightly red, yellowish tongue coating. His
pulse was weak.
Date: Dec. 1,
2010 Time: 10:00 am
The patient¡¯s conditions
were stable. He still could stand up by himself and walking was
not stable. His tongue was slightly red with slightly yellowish
tongue coating. His pulse was still weak but more powerful than
before.
Date: Dec. 6,
2010 Time: 10:00 am
Except that the patient
felt reduction on the stiffness over his lower limbs, other
conditions did not show any evident improvement. His tongue was
slightly red with yellowish tongue coating. His pulse was weak
and wiry.
Date: Dec. 11,
2010 Time: 10:00 am
After nearly 40 days
treatment, his clumsy body problem was improved. Intentional
tremor was reduced. His hands were flexible than before. He
could fetch things directly and correctly. His spiritual sense
was more alert. Speech was clearer. Stiff muscles were reduced.
Nystagmus dispelled. Sweating was better. His swallowing problem
was also better. Saliva was less. With his mother¡¯s help, he
could walk around for several minutes. He could make bowel
movement by himself on the sit-squat toilet. His tongue was
slightly red with thin and greasy tongue coating. His pulse was
more powerful than before.
Date: Dec. 16,
2010 Time: 10:00 am
The patient suffered
from cramps in the recent days. Tremor increased a little bit.
Times for eyelids blinking were a little more than before. He
could turn over his own body during night sleep. Other
conditions were stable. His tongue was slightly red with thin
and greasy tongue coating. His pulse was more powerful than
before.
Date: Dec. 21,
2010 Time: 10:00 am
The patient said
cramps and tremor
improved. Times for eyelids blinking were reduced. Fingers
movement was better. He could walk around for several minutes
with the help of his mother. His tongue was slightly red with
thin, dry and greasy tongue coating. His pulse was slightly
wiry.
Date: Dec. 26,
2010 Time: 10:00 am
Conditions of the
patient were stable these days without any evident improvement.
His tongue coating was thin and greasy. His pulse was slightly
wiry. Saliva in his mouth was a little bit sticky.
Date: Nov. 1,
2010 Time: 10:00 am
Sarfaraz decided to
leave the hospital today. After 63 days¡¯ TCM comprehensive
treatment here in our hospital, he achieved some improvement in
his conditions. With the TCM treatment method of tonifying the
kidney essence and of promoting the marrow for filling the brain
as well as of softening muscles to quicken the network channels
and transforming phlegm and opening the orifices, his rigidity
body and cramps were reduced a lot. His hands were much more
flexible than before, and at present, he could fetch tings
directly and correctly. His spiritual sense was more alert. His
speech was clearer. There was no more abnormal sweating. His
swallowing problem was cured. Saliva was reduced. He could walk
around for several minutes with the help of his mother. His
urination and stool were normal. His tongue was slightly red
with thin and greasy tongue coating. His pulse was weak and wiry
but a little bit powerful than before.
Doctor¡¯s advice after
leaving hospital:
1. Avoid wind-cold,
maintain good moods, and take care of the diet.
2. Take 4 months¡¯ herbal
medicine back for continuing treatment.
3. Keep
doing exercises.¡¡
