Brief
Summary:
On Apr. 19, 2009, Fadwa from
Jordan, who has suffered from MS,
accompanied with the symptoms of the stiffness, numbness and
weakness of the lower limbs for 6 years, was hospitalized in
your hospital. She has achieved obvious improvement after 59
days TCM treatment here.
Record of Hospitalization
Name:
Fadwa Birthpalce: Jordan
Sex:
Female Profession: Housewife
Age:
54 Date of Admission: Apr. 19, 2009
Nationality:
Jordan Date of
Record: Apr. 19, 2009
Marital Status:
Married Onset Season:
Vernal equinox
Complainer:
The patient herself
First Medical Record
Date: Apr. 19, 2009 Time:
19: 00 p. m.
Fadwa, a 54-year-old female, has suffered from MS, accompanied
with the symptoms of the stiffness, numbness and weakness of the
lower limbs for 6 years. She was hospitalized in our hospital at
19: 00 p. m. on Apr. 19, 2009.
Essentials for Diagnosis:
1. The
patient has suffered from the stiffness, numbness and weakness
of the lower limbs for 6 years.
2. In
Apr. 2003, the patient began to feel the stiffness, numbness and
weakness of the lower limbs, so she went to a local hospital for
examination and was diagnosed with MS. Then she was given
steroids for the
treatment, but there was no obvious improvement and it gradually
became more serious. She began to loose balance and could not
walk alone. She had limping gait when walking. In order to
search for further treatment, she came to our hospital at 19: 00
p. m. on Apr. 19, 2009. Since she suffered from the disease, her
spirit and appetite were not good. Her sleep was ok. Her bowel
movement was normal. She had frequent and urgent urination as
well as urinary incontinence.
3. T
36.2¡æ,
P 78 times/minute, R 20 times/minute, BP 110/70 mmHg.
4. She
grew normally with common nutrition. Her mind was clear. She had
an expression of chronic illness and tiredness. Her body was in
a positive posture and she was cooperative with clear mind.
5. The
patient felt the stiffness, numbness and weakness for 6 years of
the lower limbs, especially the left lower limb. She could not
keep balance and walk alone. She had limping gait
when walking. She had frequent and urgent urination as well as
urinary incontinence. Besides, there were the
symptoms of dizziness, blurred vision, shortness of breath,
weakness, dry and bitter mouth.
6. No
thoracic deformity. Sound of breath was bilaterally normal on
auscultation. No sound of pleural friction. Heart border was
normal. Heart beat was 78 times/minute. Cardiac rhythm was
regular. No pathological murmurs on auscultation.
7. Accessory
examination: None.
Diagnostic Basis:
TCM: The patient has suffered from the stiffness, numbness and
weakness of the lower limbs for 6 years. Damp-heat invading the
skin and then entering the channels and network vessels resulted
in obstruction of qi and blood. Then the patient felt the
weakness of the limbs. The downward movement of the dampness
caused the deterioration of the lower limbs. So it was diagnosed
as wilting pattern.
Western Medicine: The patient has suffered from the stiffness,
numbness and weakness of the lower limbs for 6 years, especially
the left lower limb. She could not keep balance and walk alone.
She had limping gait when walking. Besides, there were the
symptoms of dizziness, blurred vision,
frequent and urgent urination as well
as urinary incontinence. So she was diagnosed with
MS.
Diagnostic Differentiation:
TCM: The patient¡¯s wilting pattern should be differentiated from
impediment pattern. Wilting pattern is mainly characterized by
limp, weak and emaciated limbs with the numbness of the muscles.
However, impediment pattern is generally characterized by joint
pains. So they are not difficult to be distinguished.
Western Medicine: The patient¡¯s MS should be differentiated from
neuromyelitis
optica. The symptoms of neuromyelitis optica are limited to the
lesion parts of the optic nerve and spinal cord.
There are no symptoms of cranial
nerve palsy, nystagmus,
language disorders, ataxia,
etc. So they are not difficult to be distinguished.
First Diagnosis:
TCM diagnosis: Wilting pattern
Symptom identification: damp-heat obstructing the network
vessels.
Western Medicine diagnosis: MS
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.
Low-fat diet.
5. TCM
treatment strategy: clear heat, disinhibit dampness, soothe the
sinews, quicken the network vessels, boost qi and nourish yin.
6. Herbal
tea: one dosage a day and drink twice.
7.
Acupuncture and massage: once a day.
8. Strengthen
the functional exercises: once a day.
9. Have
more medical examinations if necessary.
Date: Apr. 20, 2009 Time:
11: 00 a. m.
The patient felt the stiffness, numbness and weakness for 6
years of the lower limbs, especially the left lower limb. She
could not keep balance and walk alone. She had limping gait when
walking. There were the symptoms of dizziness, blurred vision,
shortness of breath, weakness, pains on the shoulders and back,
dry and bitter mouth,
frequent and urgent urination as well
as urinary incontinence. Her tongue was red with
tooth marks on the edges of the tongue. Her tongue coating was
thin and yellow. Her pulse was deep, thready and weak. She had
the difficulty in raising the left lower limb. Fifteen years
ago, she went to a local hospital for examination and was
diagnosed with MS due to double vision. Then she was given
steroids for the
treatment and her double vision was controlled basically. From
the theory of Traditional Chinese Medicine, she was diagnosed
with wilting pattern due to damp-heat
obstructing the network vessels. But from the view of western
medicine, she had suffered from MS. So the treatment strategy
was to clear heat, disinhibit dampness, soothe the sinews,
quicken the network vessels, boost qi and nourish yin. The
prescription was as follows: danshen (salvia
root), huangqi (astragalus root), etc. 4 dosages in total.
Date: Apr. 21, 2009 Time:
15: 00 p. m.
She slept very well last night. Her diet, urine and bowel
movement were normal.
The routine examinations of the blood and urine, the function of
the liver and kidneys, E4A, anti ¡°O¡±,
ESR, TG, etc. were normal. Professor Zhang suggested her take
the food low in fat and strengthen the functional exercises.
Date: Apr. 23, 2009
The patient had the symptoms of dizziness, tinnitus,
urinary incontinence, blurred vision and dry mouth, so she
consciously took some western medicine. Professor Zhang
suggested her to take the western medicine when it was
requested. The former prescription was changed as follows: gouqi
(lycium berry), gancao (licorice
root), chuanxiong (ligusticum root), etc. 5 dosages in total.
Date: Apr. 28, 2009
The numbness and coldness of the left lower limb were improved.
Besides, she felt the mouth dry, but the patient thought it was
due to the western medicine. So the treatment strategy was
changed to quicken the blood circulation, soften hardness,
enrich and supplement the liver and kidneys. The prescription
was as follows: gancao (licorice root), qinjiao (large gentian
root), etc. 4 dosages in total.
Date: May 2, 2009
The symptom of
urinary incontinence was obviously improved. She stopped to take
the western medicine for 3 days which was used to treat urinary
incontinence. She just had urination once during the night.
Besides, there was some improvement of the stiffness and
weakness of the lower limbs as well as walking. The patient
herself and her family were satisfied with the result. Continue
to take the former prescription. 5 dosages in total.
Date: May 7, 2009
The patient stopped to take the western medicine for 8 days.
During these days, there was no symptom of urinary incontinence.
Besides, the symptoms of the stiffness, numbness and weakness of
the lower limbs as well as the difficulty in walking were
obviously improved. Her tongue coating was thin and white. Her
tongue was red. The tooth marks on the edges of the tongue
together with thready and weak pulse became better. The former
prescription was changed a little. 5 dosages in total.
Date: May 12, 2009
There was no symptom of urinary incontinence during the recent
10 days. The stiffness and weakness of the lower limbs were
further improved. She didn¡¯t feel the sense of numbness.
Continue to take the same prescription. 5 dosages in total.
Date: May 17, 2009
She could do more exercise than before. The stiffness, weakness
and numbness of the lower limbs were obviously improved. She
could raise her lower limbs normally. She had night urination
once, and there was no symptom of urinary incontinence. She felt
the mouth slightly dry. Her diet and sleep were normal. Her
tongue was red. Her tongue coating was thin and yellow with
scant fluids. The prescription was changed as follows:
gancao (licorice root), huangqi
(astragalus root), etc. 5 dosages in total.
Date: May 20, 2009
Yesterday the patient fell down due to carelessness which
resulted in the
blood stasis and pains of the
lumbosacral portion and inconvenience in walking. Besides,
dietary irregularities resulted in her vomiting and diarrhea
once. Today she was given the
plaster for external application
in combination with oral taking notoginseng root power for
further observation. Meanwhile, Professor Zhang suggested her
not take cold food and avoid falling down again.
Date: May 22, 2009
The pains on the lumbosacral portion lessened. She didn¡¯t feel
the mouth dry. She had thin sloppy stool. Her urine was normal
and she had urination once every night. There was no symptom of
urinary incontinence. The former prescription was changed as
follows: chuanxiong (ligusticum
root), dangshen (codonopsis root), etc. 4 dosages in total.
Date: May 26, 2009
The pains on the lumbosacral portion further lessened. She could
do some exercises outside. There was some improvement of the
blurred vision. Her urine and bowel movement were normal. She
didn¡¯t feel the mouth dry and bitter. The prescription was
changed as follows: honghua
(carthamus flower), gancao (licorice root), etc. 5 dosages in
total.
Date: May 30, 2009
The traumatic pains
on the lumbosacral portion basically recovered. Today she could
go out to do some functional exercises as usual. The stiffness
and weakness of the lower limbs was obviously improved. She
could walk alone for 3-4 meters and there was no symptom of
lameness. The patient requested to lose weight. She kept in a
good mood. The former prescription was changed a little. 5
dosages in total.
Date: Jun. 5, 2009
The symptoms of
frequent and urgent urination as well
as urinary incontinence were cured completely. Her
vision became better. The pains on the waist and back recovered.
The stiffness and weakness of the lower limbs was further
improved. She could walk alone for 4-5 meters and there was no
symptom of lameness. She could raise her legs normally. Her diet
and sleep were normal. Her weight increased 3 kg. She kept in a
good mood. She didn¡¯t feel the mouth dry and bitter. Her tongue
coating was white. Her tongue was red. Her pulse was thready and
slightly weak. The prescription was changed as follows: gouqi (lycium
berry), danpi (moutan root bark), etc. 5 dosages in total.
Date: Jun. 10, 2009
Her condition was further improved. Continue to take the same
prescription.
Date: Jun. 16, 2009
The
urinary incontinence was controlled after 10 days comprehensive
treatment including herbal tea,
acupuncture and massage. The stiffness, numbness and weakness of
the lower limbs and difficulty in walking were gradually
improved. Now she could walk alone for about 10 meters and there
was no symptom of lameness. Besides, she could raise her legs
normally. The blurred vision became better. The patient herself
and her family were satisfied with the result. She decided to
leave the hospital with taking 60 days herbal tea back to home
for continuous treatment.¡¡
More other
successful treatment cases for MS:
Case-1
Case-2 Case-3
Case-4 Case-5
Case-6
Case-7
Case-8
Case-9 Case-10
Case-11
Case-12 Case-13 Case-14
Case-15
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