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Records of Hospitalization

Name: Arun                                                                          Sex: Male

Nationality: India                                                                   Age: 11  

Marital status: Unmarried                                                       Date of Admission: Apr. 22nd, 2007

Onset Season: Summer                                                          Date of Report: Apr. 22nd, 2007

Complainer : The patient’s father                                            Reliability: Reliable

Major complaints: The patient has suffered from lower limb weakness and lame walking four years accompanied by an aggravated duck-gait for two years.

Present illness:

At the end of 2003, the patient had a change in walking posture without any evident predisposing cause. He began to slow down his walking speed and felt weakness on his lower limbs. At that time, his family neither paid much attention on his condition, nor took him to do any examination and treatment. In 2005, the patient’s condition was aggravated. He had difficulties in walking without balance and often fell down. He needed to turn over and slowly picked himself up when he was spinning in bed.  He walked with duck-gait posture. He was taken to a local hospital and got the definite diagnosis for with Progressive muscular dystrophy (DMD) by MRI test. The doctor told him there was no therapeutic schedule for this disease, so he was not given any treatment until now. He was picked up by our workers and arrived in Huaihua Red Cross Hospital for treatment on April 22nd, 2007. The patient has good spirit, appetite and sleep. His bowel movement and urination are normal.

Past history: No history of typhoid, tuberculosis or hepatitis. No history of food or medicine allergy. No history of operation or blood transfusion.  On April 29th, 1998, he was given BCG vaccination.

Personal history: He was born in India. He is the first child by natural delivery. He lives in a dry environment. No contact history of schistosomiasis. No addiction to alcohol, smoking or special food. He is calm and cheerful.

Marital history: Unmarried.

Family history: No family history of special disease.

 

Physical examination

T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg, W 37.5kg.

He is mid-nourished and normally developed. His mind is clear. Chronic face mirroring difficult condition. Languor expression, in a positive position and cooperative in examination. His skin is moist. No jaundice in the sclera. No superficial lymph-node enlargement. Bilateral pupils are round, equal in size and sensitive to light. No thoracic deformity. Sound of breath is bilaterally normal on auscultation. No respiratory rales or pleural friction rubs. Heart border is not big. Heart beat 98bpm. Cardiac rhythm is regular. No pathological murmurs of heart on auscultation. Abdomen is flat and soft without tenderness or rebound tenderness. Liver and spleen are not palpable. No percussion pain on renal region. Bowel sound is normal. No Spinal and pelvic deformity or tenderness. Both upper limbs have no deformity and normal mobility. The patient has suffered from lame walking accompanied by a duck-gait. He can not run and has difficulties in stepping up the stairs. He often falls down. He has to turn over when lying face upward and used his two hands holding his knees to slowly rise upward. Both side of his gastrocnemius are hypertrophic and hard. The myodynamia of his lower limbs are grade III and myatonia. Straight leg raising test: left leg is 5 degrees and the right leg is 5 degrees.  The development of the anus or genital is normal. Physiological reflex has not been elicited. Red tongue, thin and white tongue fur, fine and deep pulse. 

Accessory examination: Not provided yet.

First diagnosis: TCM diagnosis: Wei-syndrome (flaccidity syndrome)

Symptom diagnosis: Spleen and stomach asthenia; liver and kidney asthenia.

WM diagnosis: Progressive muscular dystrophy (DMD).

Dr. Yang Qingzhi/ Dr. DaiLei

April 22nd, 2007

 

 

First Medical Record

Arun, 11-year-old male, has suffered from lower limb weakness and lame walking four years accompanied by an aggravated duck-gait for two years. He was picked up by our workers and arrived in Huaihua Red Cross Hospital for treatment on April 22nd, 2007.

Case characteristics:

1. The patient has suffered from lower limb weakness and lame walking four years accompanied by an aggravated duck-gait for two years.

2. At the end of 2003, the patient had a change in walking posture without any evident predisposing cause. He began to slow down his walking speed and felt weakness on his lower limbs. At that time, his family neither paid much attention to him, nor took him to do any examination or treatment. In 2005, the patient’s condition was aggravated. He had difficulties in walking and with imbalance. He often fell down. He needed to turn over and slowly picked himself up when he was spinning in bed. He walked with duck-gait posture. He was taken to the local hospital and the definite diagnosis for him was Progressive muscular dystrophy (DMD) by MRI test. The doctor told them there was no therapeutic schedule for his disease. He was not given any treatment until now. He was picked up by our workers and arrived in Huaihua Red Cross Hospital for treatment on April 22nd, 2007. The patient has good spirit, appetite and sleep since the disease onset. His bowel movement and urination are normal.

3. T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg, W 37.5kg.

4. He is mid-nourished and normally developed. His mind is clear, chronic face mirroring difficult condition, languor expression, in a positive position and cooperative in examination.

5. The patient is suffering from lame walking and accompanied by a duck-gait. He can not run and has difficulties in stepping up the stairs. He has to turn over when lying face upward. He has to use his two hands holding his knees to slowly rise upward. Both side of his gastrocnemius are hypertrophic and hard. The myodynamia of his lower limbs are grade III and myatonia. Straight leg raising test: left leg is 5 degrees (+) and the right leg is 5 degrees (+).

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

7. Accessory examination: Not provided yet.

Diagnostic basis

TCM: The patient has suffered from lower limb weakness and lame walking four years accompanied by an aggravated duck-gait for two years. Wei-syndrome (flaccidity syndrome) refers to the flaccidity and weakness of extremities leading to muscular atrophy and less liberty in movement. Due to spleen and qi deficiency, qi and blood insufficiency of the source of transformation, sinews deprived of nourishment and qi-blood lack of source can not nourish the body and sinews which lead to limp wilting limbs. Kidney governs bones and essence-marrow insufficiencies are the main cause of limp wilting lumbus and knees.

Western medicine basis: The patient has suffered from lower limb weakness and lame walking four years accompanied by an aggravated duck-gait for two years. He can not run and difficulties in stepping up the stairs. He has to turn over when lying face upward. He has to use his two hands to hold his knees to slowly rise upward. Both side of his gastrocnemius are hypertrophic and hard. The myodynamia of his lower limbs are grade III and myatonia. Straight leg raising test: left leg is 5 degrees (+) and the right leg is 5 degrees (+). The MRI test, which he took in his country, showed he got Progressive muscular dystrophy (DMD).

Diagnostic differentiation: TCM: The patient’s Wei-syndrome should be differentiated from Bi-syndrome. Although both of them fall into the category of limb disease, they are different in pathogeny, pathogenesis and clinical manifestations. Wei-syndrome is characterized as limp, weak and emaciated limbs with shriveled muscles. A patient suffering from Wei-syndrome may even become unable to hold an object or to stand without support. Besides, the patient’s lower limbs are more often affected, though he or she usually has no joint pain. On the contrary, Bi-syndrome is generally characterized of aching pain, fixed heaviness and inflexibility of sinews and bones, muscles and joints, with occasional numbness or swelling, though, no paralytic manifestations. These should be differentiated.

WM differentiated from amyotrophic lateral sclerosis: Most patients get the disease between the ages of 30 to 50. This kind of disease has a slow onset. Most of the patient start onset from one side of the body limbs, later on it develops into both sides. The common onset pattern starts from the upper limbs, showing inflexible movement and muscular dystrophy, indicated as "claw hand", and then gradually developing to the forearm, upper arm and shoulder muscles, with aggravation of the muscular dystrophy, weakness of the limbs leading to paralysis. These should be distinguished.

 

First diagnosis

TCM diagnosis: Wei-symptom (flaccidity syndrome)  

Symptom diagnosis: Spleen and stomach asthenia; liver and kidney asthenia.

WM diagnosis: Progressive muscular dystrophy (Pseudo-mast); “DMD”.

Plan of the treatment:

1. On routine care of traditional Chinese internal medicine

2. On grade II care

3. Nurse

4. Low salt, sugar and fat diet

5. Herbal tea: Boost Qi and fortify the spleen, supplement the kidney and strengthening the sinew. Such as Huangqi (Astragalus), Danggui (Angelicae sinensis radix), Baisheng (white ginseng) etc. One dosage a day and drink by twice.

6. Acupuncture once a day

7. Massage once a day

8. Have more medical examinations if necessary

Dr. Yang Qingzhi/ Dr. DaiLei

 

Date: April 22nd, 2007                                     Time: 9:00 a.m.   

Deputy Chief Physician rounds

This morning is Deputy Chief Physician Yang Qingzhi’s ward-round. The patient complains that his lower limb weakness and lame walking. He can not run, often fall down and has difficulties in stepping up the stairs. He walks in a duck-gait posture. Today’s Examination: His bowel movement, urination and blood routine examinations are all normal. His liver and kidney functions and hepatitis B tests are also normal. T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg, W 37.5kg. Heart and lung (), Abdomen is flat and soft (). Deputy Chief Physician Yang Qingzhi analyzed as the following:  

1. The patient has been suffering from lower limb weakness and lame walking four years accompanied by an aggravated duck-gait for two years.

2. The patient suffers from lame walking and accompanied by a duck-gait. He can not run and has difficulties in stepping up the stairs. He has to turn over when lying face upward. He has to use his two hands holding his knees to slowly rise upward. Both side of his gastrocnemius are hypertrophic and hard. The myodynamia of his lower limbs are grade III and myatonia. Straight leg raising test: left leg is 5 degrees (+) and the right leg is 5 degrees (+).

3. The definite diagnosis for the patient is progressive muscular dystrophy “DMD” by the MIR test in the local hospital of India. According to the materials above stated, TCM considered it is Wei-symptom. Wei-syndrome (flaccidity syndrome) refers to the flaccidity and weakness of extremities leading to muscular atrophy and less liberty in movement. In clinical terms: It often seen the lower limb wilting and weakness, and also named “wilting-bi’. Due to spleen-stomach vacuity, qi-blood insufficiency of the source can not nourish the body and sinews which lead to limp-wilting limbs. Kidney governs bones, but essence-marrow insufficiency is the main cause of limp wilting lumbus and knees. Dialectical: Spleen and stomach asthenia; liver and kidney asthenia. Treatment principle: Boost Qi and fortify the spleen, supplement the kidney and strengthen the sinew. Prescription: Two Immortals Decoction of kidney-enrich. The herbals are Huangqi (Astragalus), Danggui (Angelicae sinensis radix), Baisheng (white ginseng) etc. One dosage a day and drink by twice, three days.

Acupuncture and massage once a day; have more medical examinations if necessary.

Dr. Yang Qingzhi/ Dr. DaiLei

 

Date: 23rd of April 2007                                Time: 9:00 a.m.

Today the patient still complains that his lower limb weakness and lame walking. No aversion to cold. No fever. No headache or dizziness. No nausea or vomiting. He presents with a good spirit. His sleep is good. His bowel movement and urination are normal. Physical check: T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg. Heart and lung (), Abdomen is flat and soft (). The examinations of electrocardiogram (ECG) and X-ray film of his lung are both normal. Slight reddish tongue, thin and white tongue fur, fine and weak pulse. The prescription is the same as before. 

Dr. Yang Qingzhi/ Dr. DaiLei

 

Date: 24th of April 2007                                Time: 9:00 a.m.

Today the patient still complains that his lower limb weakness and lame walking. No aversion to cold. No fever. No headache or dizziness. No nausea or vomiting. He presents with a good spirit. His sleep is good. His bowel movement and urination are normal. Physical check: T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg. Same examination is on his lower limbs. Slight reddish tongue, thin and white tongue fur, fine and deep pulse. The same prescription is as before. Ask the patient to strengthen the limb functional training. 

Dr. Yang Qingzhi/ Dr. DaiLei

 

Date: 26th of April 2007                                Time: 9:00 a.m.

Today the patient still complains that his lower limb weakness and lame walking by duck-gait walking posture. No aversion to cold. No fever. No headache or dizziness. No nausea or vomiting. He presents with a good spirit. His sleep is good. His bowel movement and urination are normal. Physical check: T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg. The same examination is on his lower limbs. The X-ray examination on his pelvis and hip-joint are both normal. Slight reddish tongue, thin and white tongue fur, fine and deep pulse. The prescription is the same as before.

Dr. Yang Qingzhi/ Dr. DaiLei

 

Date: 1st of May 2007                                Time: 9:00 a.m.

Today the patient does not complain any other special discomfort. He still complains that his lower limb weakness and lame walking by duck-gait walking posture. No aversion to cold. No fever. No headache or dizziness. No nausea or vomiting. He presents with a good spirit. His sleep is good. His bowel movement and urination are normal. Physical check: T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg. The same examination is on his lower limbs. Ask the patient to strengthen the limb functional training. Slight reddish tongue, thin and white tongue fur, fine and deep pulse. The same prescription is as before. The herbals are Huangqi (Astragalus), Danggui (Angelicae sinensis radix), Baisheng (white ginseng) etc. One dosage a day and drink by twice, five days.

Dr. Yang Qingzhi/ Dr. DaiLei

 

Date: 5th of May 2007                                Time: 9:00 a.m.

Today the patient does not complain any other special discomfort. He still complains that his lower limb weakness and lame walking by duck-gait walking posture. No aversion to cold. No fever. No headache or dizziness. No nausea or vomiting. He presents with a good spirit. His sleep is good. His bowel movement and urination are normal. Physical check: T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg. The same examination is on his lower limbs. Ask the patient to strengthen the limb functional training. Slight reddish tongue, thin and white tongue fur, fine and deep pulse. The prescription is the same as before.

Dr. Yang Qingzhi/ Dr. DaiLei

 

Date: 9th of May 2007                                Time: 9:00 a.m.

Today the patient does not complain any other special discomfort. He still complains that his lower limb weakness and lame walking by duck-gait walking posture. No aversion to cold. No fever. No headache or dizziness. No nausea or vomiting. He presents with a good spirit. His sleep is good. His bowel movement and urination are normal. Physical check: T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg. The same examination is on his lower limbs. Ask the patient to strengthen the limb functional training. Slight reddish tongue, thin and white tongue fur, fine and deep pulse. The same prescription is as before. The herbals are Huangqi (Astragalus), Danggui (Angelicae sinensis radix), Baisheng (white ginseng) etc. One dosage a day and drink by twice, five days.

Dr. Yang Qingzhi/ Dr. DaiLei

 

Date: 13rd of May 2007                                Time: 9:00 a.m.

Today the patient does not complain any other special discomfort. He still complains that his lower limb weakness and lame walking by duck-gait walking posture. No aversion to cold. No fever. No headache or dizziness. No nausea or vomiting. He presents with a good spirit. His sleep is good. His bowel movement and urination are normal. Physical check: T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg. The same examination is on his lower limbs. Ask the patient to strengthen the limb functional training. Slightly reddish tongue body. Thin and white tongue fur. Fine and deep pulse. The same prescription is as before.

Dr. Yang Qingzhi/ Dr. DaiLei

 

Date: 17th of May 2007                                Time: 9:00 a.m.

Today the patient does not complain any other special discomfort. He complains that his lower limb weakness and lame walking by duck-gait walking posture. No aversion to cold. No fever. No headache or dizziness. No nausea or vomiting. He presents with a good spirit. His sleep is good. His bowel movement and urination are normal. Physical check: T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg. The same examination is on his lower limbs. Ask the patient to strengthen the limb functional training. Slight reddish tongue, thin and white tongue fur, fine and deep pulse. The same prescription is as before.

Dr. Yang Qingzhi/ Dr. DaiLei

 

Date: 20th of May 2007                                Time: 9:00 a.m.

Today the patient does not complain any other special discomfort. He says that his lower limb weakness is less and lame walking is better, but still accompanied by duck-gait walking posture. He can walk longer distance and the time also longer. No aversion to cold. No fever. No headache or dizziness. No nausea or vomiting. He presents with a good spirit. His sleep is good. His bowel movement and urination are normal. Physical check: T 36.3P 88bpm, R 24bpm, BP: 100/70mmHg. The same examination is on his lower limbs. Ask the patient to strengthen the limb functional training. Slight reddish tongue, thin and white tongue fur, fine and deep pulse. The same prescription is as before. He will be leaving the hospital tomorrow.     

Dr. Yang Qingzhi/ Dr. DaiLei