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 36.3¡æ£¬P
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 36.3¡æ£¬P
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 36.3¡æ£¬P
88bpm, R 24bpm, BP: 100/70mmHg, W 37.5kg. Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
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 36.3¡æ£¬P
88bpm, R 24bpm, BP: 100/70mmHg. Heart and lung (¡ª),
Abdomen is
flat and soft (¡ª).
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 36.3¡æ£¬P
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 36.3¡æ£¬P
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 36.3¡æ£¬P
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 36.3¡æ£¬P
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 36.3¡æ£¬P
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 36.3¡æ£¬P
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 36.3¡æ£¬P
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 36.3¡æ£¬P
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
