Brief Summary: On January 17, 2010, Kamal from Bahrain, who has suffered from MS, was hospitalized in our hospital. He had weakness of the lower limbs for 15 years. Besides, he had incontinence of urine for 5 years. After 56 days treatment here, he had got much improvement.

 

Record of Hospitalization

Name: Kamal                                                                                                      Birthplace: Bahrain

Sex: Male                                                                                                            Profession: Business man

Age: 49                                                                                                                Date of Admission: January 17, 2010

Religion: Muslim                                                                                                  Date of Record: January 17, 2010

Marital Status: Married                                                                                       Onset Season: Heavy Snow

Complainer: The patient himself. The case was recorded by TCM group.

 

First Medical Record

Date: January 17, 2010                                       Time: 19: 30 p. m.

Kamal, a 49-year-old male, who has suffered from MS, was hospitalized in our hospital on January 17, 2010.

Essentials for Diagnosis:

1. The patient has suffered from weakness of the lower limbs for 15 years. Besides, he had incontinence of urine for 5 years.

2. The patient began to feel weakness of the lower limbs and the blurred vision of the left eye without obvious reason. Besides, he had incontinence of urine for 5 years. Then he went to a local hospital and he was given MRI examination. He was diagnosed with MS. He was given a certain kind of injection called "interferon inducer", three times for each week. However, he did not get obvious improvement after five year's treatment. In January of 2010, he stopped his previous treatment. At that time, he could not walk by himself because of the weakness of the lower limbs. To pursue the comprehensive treatment, on January 17, 2010, he came to our hospital.

3. T 36.3≧, R 20 times/minute, P 80 times/minute, BP 120/80mmHg.

4. He grew normally with excessive nutrition. His mind was clear. He had an expression of chronic illness and tiredness. His body was cooperative with his mind.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. Accessory examination: none.

Diagnostic Basis:

TCM:  The patient has suffered from the symptom of weakness of the lower limbs for 15 years. He had blurred vision of left eye. Besides, he had incontinence of urine for 5 years. He went to a local hospital and he was given MRI examination. He was diagnosed with MS. Then he was given a certain kind of injection called "interferon inducer", three times for each week. However, he did not get obvious improvement after five year's treatment. His case was due to disharmony of the qi and blood, obstruction of dampness and coldness in the network vessels. So our treatment was to boost qi and quicken the blood circulation, dissipate coldness and expel dampness. He  got much improvement after his treatment here. His tongue was pale. His tongue coating was thin and slight white. His pulse was wiry and thready. According to the symptoms of the tongue and pulse, he was diagnosed with impediment pattern.

Western Medicine: The patient has suffered from the symptom of the weakness of the lower limbs for 15 years. He had blurred vision of left eye. Besides, he had incontinence of urine for 5 years. In 1995, he was diagnosed with MS by MRI in his local hospital.

Diagnostic Differentiation:

TCM: The patient's impediment pattern should be differentiated from wilting pattern. Wilting pattern is characterized by limp, weak, and emaciated limbs with the numbness of the muscles. But the patient usually has no joint pains. On the contrary, impediment pattern is generally characterized by joint pains. So they are not difficult to be distinguished.

Western Medicine: MS should be differentiated from ophthalmoneuromyelitis. Ophthalmoneuromyelitis is a kind of disease that the symptoms are in the optic nerve and damaged segments of the spinal cord. It is characterized by thrill of eyeball, language barrier, but no paralysis of cranial nerve. So they are not difficult to be distinguished.

First Diagnosis:

TCM diagnosis: Impediment pattern

Symptom identification: vacuity of the liver and kidneys, sinews and vessels deprived of nourishment.

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. Common food.

5. TCM treatment strategy: enrich the liver and the kidneys, soothe the sinews and free the network vessels.

6. Herbal tea: one dosage a day and drink twice.

7. Acupuncture and massage: once a day.

8. Have more medical examinations if necessary.

 

Date: January 18, 2010                                       Time: 11: 00 a. m.

The patient had weakness of his both lower limbs. And he had had difficulty in walking. Then he came to our hospital on January 17, 2010 for comprehensive  treatment. From the idea of TCM (Traditional Chinese Medicine), his condition was due to sinews and vessels deprived of nourishment, vacuity of the liver and kidneys. Then our strategy was to soothe the sinews and free the network vessels and enrich the liver and the kidneys. So our expert team prescribed a special formula for him. 

 

Date: January 21, 2010                                      Time: 10: 00 a. m.

The patient¨s condition was the same and had no obvious improvement. His tongue was pale. His tongue coating was thin and slight white. His pulse was wiry and thready. Then we changed the formula a little for the first time. 　

 

Date: January 26, 2010                                      Time: 10: 00 a. m.

The patient could feel the strength of the lower limbs. Besides, his incontinence of urine had got some improvement. His spirit was good as well as his appetite. However, he had stinging pains of the left sole sometimes. According to his latest condition, we prepared a new formula again for the second time.

 

Date: February 1, 2010                                       Time: 10: 00 a. m.

The patient felt good. He could feel more strength of his two lower limbs. Besides, the condition of the stinging pains had got much improvement. He had no incontinence of urine in recent days. The tongue body was dark red. Then he was told to continue to use the above formula to consolidate the result.

 

Date: February 6, 2010                                       Time: 10: 00 a. m.

The patient's feedback was good. He can walk by himself by the help of holding something. However, his blurred vision had no obvious improvement. Then we changed his above formula a little.

 

Date: February 11, 2010                                        Time: 10: 00 a. m.

The patient's spirit, appetite and sleeping were in normal condition. At the same time, his walking had got much improvement. He told us that he could walk about 100 meters by the help of holding something. His blood pressure was normal. Then we changed his formula a little for the second time to let him get further progress.

 

Date: February 21, 2010                                        Time: 10: 00 a. m.

The patient's condition was stable. So he was told to use the same formula to consolidate the result.

 

Date: February 26, 2010                                        Time: 10: 00 a. m.

The patient told us that his spirit was very good. His strength of the lower limbs had increased by 5%. His tongue body was red. So he continued to take the same formula.

 

Date: March 1, 2010                                           Time: 10: 00 a. m.

The patient's condition was good. He also felt very well. So he still used the above formula.

 

Date: March 6, 2010                                           Time: 10: 00 a. m.

The patient's spirit was good as well as his appetite and sleep. The most important thing was that, the patient could stand up by himself in recent four days.

 

Date: March 6, 2010                                           Time: 10: 00 a. m.

The patient said that everything was going smoothly these days. His condition was stable. He felt very satisfied with the improvement. 

 

Date: March 14, 2010                                         Time: 10: 00 a. m.

Compared with before, his condition got obvious improvement. After 56 days of comprehensive treatment here including herbal tea, massage and acupuncture, the symptoms improved a lot. He could stand up by himself. His spirit, appetite and sleeping were OK. The patient decided to leave the hospital tomorrow.

 

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