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Brief Summary: On April 22, 2013, Adel, from Saudi Arabia, who has been suffering MS(multiple sclerosis) with the symptoms of finger-shaking, unstable walking, curved body and double vision for 12 years, and having to use a stick to walk for a few years, accompanied by pains over his back and legs for two weeks, was hospitalized in our hospital. He achieved great improvement after almost two months¡¯ TCM treatment with the help of acupuncture, herbal tea and tuina in our hospital. He could walk straightly without using his stick again.

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Record of Hospitalization

Name: Adel                                                                Sex: Male

Age: 42                                                                      Marital Status: Married

Nationality: Saudi Arabian                                         Date of Admission: Apr. 22, 2013

Companion: Alone

 

First Medical Record

Date: Apr. 23, 2013                                Time: 11:00 a.m.

This 42-year-old man had been suffering from finger-shaking, unstable walking, curved body and double vision for 12 years, having to use a stick to walk for a few year, accompanied by pains over his back and legs for two weeks. The patient was hospitalized in our hospital for TCM treatment at 20:30 p.m. on April 22, 2013.

 

Essential for Diagnosis:

1. Medical history: The patient suffered finger-shaking, unstable walking, curved body and double vision for 12 years, accompanied by pains over his back and legs for two weeks. He used to have operation on appendix. Two weeks ago, he did arm wrestling with his friend, and he wrenched his waist.

2. When he came to our hospital, he suffered shaking symptom over his ten fingers without any cramps. The case of unstable walking occurred repeatedly with poor balance. And in recent one year, such case happened more often than before. He also suffered diplopia with diminution of vision. He did not suffer dizziness or tinnitus. His leg and back were painful. He could not walk upright. When he straightened his back, he felt painful. He also suffered the symptom of amnesia. He suffered sleep drooling. He suffered decreasing sexual function and erectile weakness. Urine color was yellowish. He had no night urination. He suffered constipation for several years. His stool was dry and hard. He had bowel movement for 4-5 days/time. He suffered weight-loss for 25 kg. Appetite and sleep were normal.

3. T: 36.3¡ãC   R: 20 times/minute    P: 80times/minute   BP: 120/80mmHg

4. The patient grew normally with emaciated body shape. He was alert and cooperative. He has chronic sick facial complesion. He walked with a crutch and stoop down. His eyes were reactive to light without eye fremitus. Hoffmann's sign£¨+£©, Elevation test of straight right leg (+),  Bragard Test (+). There were obvious pressing pain points over his back, especially the left side. His tongue was red with white and thick tongue coating. His pulse was wiry. His left pulse was weak.

 

Diagnostic Differentiation:

TCM:

The patient suffered finger shaking and unstable walking with poor balance for 12 years, which should be ¡°Bone-shaking¡± in the category of TCM. The ¡°Marrow Sea¡± of the patient had not been nourished for long time, and then the symptoms of finger fremitus and poor balance. The deficiency of kidney-yang led to erectile weakness. Long course of sickness led to deficiency of blood and qi, and then constipation happened. Besides, the patient suffered lumbar pains, which should be lumbago among the category of TCM. Because of sprain, he suffered pains over his back, and then he could not walk upright. The stasis of blood blocked the channels. There goes a saying: When the channels are blocked, pains happen. Therefore, his condition should be ¡°bone-shaking¡± due to un-nourishment of the ¡°Marrow Sea¡± and deficiency of blood and qi, as well as lumbago due to channel blockage by the blood stasis.

Western Medicine diagnosis:

1. The patient suffered finger shaking, unstable walking and double vision for 12 years, being severe for one year. He also suffered pains over his back and legs for 2 weeks.  

2. Positive signs of the nervous system and medical history of sprain over his back.

3. Diagnosis in his local hospital.

 

First Diagnosis:

TCM: 1. Bone Shaking.

          2. Lumbar pains.

Symptom identification: un-nourishment of the ¡°Marrow Sea¡± and deficiency of blood and qi as well as channel blockage by the blood stasis.

Western medicine diagnosis: 1. multiple sclerosis£¨MS£©.                    

                                           2. Prolapse of lumbar intervertebral dissc.

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢ò care.

3. Common diet.

4. Pathogenesis: un-nourishment of the ¡°Marrow-Sea¡± and deficiency of blood and qi as well as channel blockage by the blood stasis.

5. TCM strategy: promoting the circulation of blood to remove blood stasis and to stop pains, reinforcing the kidney and replenishing essence to tonify the marrow, qi and blood.

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: Apr. 24, 2013                                            Time: 09:00 a.m.

President Dr. Ming, doctor-in-charge, paid a visit to the patient. The patient suffered finger- shaking, unstable walking, curved body and double vision for 12 years, accompanied by pains over his back and legs for two weeks. The case of unstable walking occurred repeatedly with poor balance. And in recent one year, such case happened more often than before. He also suffered the symptom of amnesia. His leg and back were painful. He could not walk upright. When he straightened his back, he felt painful. He suffered decreasing sexual function and erectile weakness. His stool was dry and hard. He had bowel movement for 4-5 days/time. He suffered weight-loss for 25 kg. Appetite and sleep were normal. Hoffmann's sign£¨+£©, Elevation test of straight right leg (+),  Bragard Test (+). There were obvious pressing pain points over his back, especially the left side. His tongue was red with white and thick tongue coating. His pulse was wiry. His left pulse was weak. The patient said his condition has been diagnosed as MS in his local hospital. MRI over his back: L5, S1 presented degenerative change; L4, L5 presented prolapse of lumbar intervertebral disc. He used to have medical history of sprain over his back. Dr. Ming thought from the view of TCM that his condition should be ¡°bone-shaking¡± due to un-nourishment of the ¡°Marrow Sea¡± and deficiency of blood and qi, as well as lumbago due to channel blockage by the blood stasis.

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Date: Apr. 25, 2013                                            Time: 09:00 a.m.

Feedback of the examination: Blood-R: (-), Blood: LF£¨-£©, SPS(-). The patient said he did not suffered palpitation or chest depression.

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Date: Apr. 29, 2013                                            Time: 09:00 a.m.

The patient said there were no pains over his back. There were still pains over the low part of his thigh. When he straightened his back, there were drawing pains. On April 27, he injected interferon, and then he felt poor balance and unstable walking problems.

 

Date: May 1, 2013                                            Time: 09:00 a.m.

The patient said pains over his left thigh were better and he felt strength increasing. He still suffered constipation. His tongue was red with thin and thick tongue coating. His pulse was wiry, and when pressed heavily, it was powerless.

Date: May 4, 2013                                            Time: 09:00 a.m.

The patient still suffered constipation. Other conditions were the same as days before.

 

Date: May 7, 2013                                            Time: 09:00 a.m.

The patient complained that there were pains over the back side of his left thigh. When he walked a little long, he felt severe pains.

 

Date: May 10, 2013                                            Time: 10:00 a.m.

He said pains were reduced somewhat. Sometimes, his stool was dry and sometimes, it was soft. Finger fremitus happened occasionally. The main foods of the patient were biscuit, bread, sweet things and soft drinks. His life style was irregular. Doctors advised him to eat more vegetable and fruits.

 

Date: May 17, 2013                                            Time: 10:00 a.m.

Back pains of the patient became severe those days, because he had too many out-door activities. So the prescription for his should make some changes.

 

Date: May 22, 2013                                            Time: 10:00 a.m.

The patient said he still felt pains. The herbal tea was the same as yesterday. Asked him to take enough rest.

 

Date: May 26, 2013                                            Time: 10:00 a.m.

Today, the patient said pains over his back were improved obviously.

 

Date: May 29, 2013                                            Time: 10:00 a.m.

The patient said his bowel movement was much better than before. Pains were reduced.

 

Date: June 01, 2013                                            Time: 10:00 a.m.

The patient said he did not have bowel movement for four days, yet he did not felt abdominal pains or abdominal distension. Pains over his back and leg were much better. He could walk without using his stick today. His tongue coating was thick and yellowish. His pulse was wiry. When pressed heavily, it was powerful than before.

 

Date: June 06, 2013                                            Time: 10:00 a.m.

The patient said bowel movement was normal. There were obvious improvement on his back and leg pains. His pulse was wiry. When pressed heavily, it was powerful than before.

 

Date: June 10, 2013                                            Time: 10:00 a.m.

The patient said there were no more pains over his back. When he walked too long, he felt pains over the back side of his thigh. His tongue coating was red. His pulse was wiry. When pressed heavily, it was powerful than before.

 

Date: June 13, 2013                                            Time: 10:00 a.m.

The patient said, since he came to our hospital for TCM treatment, strength of his whole body were increased. His spirit was good. Pains over his back and leg were alleviated obviously. He could walk upright now without using his stick and walk long distance than before. His urination and bowel movement were normal. Appetite and sleep were good.

 

Date: June 16, 2013                                            Time: 09:00 a.m.

The patient said there were no more pains over his back and he could walk upright. His urination and bowel movement were normal. Appetite and sleep were good. The symptom of his tongue and pulse was the same as days before.

 

Date: June 19, 2013                                            Time: 09:00 a.m.

The patient said that there were very slight pains over his back and leg. He could walk longer distance than before and felt more relaxed. He could walk upright without using his stick. His urination and bowel movement were normal. After he came to our hospital, he only suffered poor balance once. Finger shaking was better than before. Sexual function and amnesia were better. His spirit was good. Appetite and sleep were normal. He felt more relaxed and energetic than before. His tongue was red with thin coating. His pulse was more powerful than before. Because of the expiration of his visa, he decided to leave our hospital today.

 

Doctor¡¯s advice after leaving the hospital:

1. Avoid wind-cold. Keep a good mood.

2. Avoid strenuous exercise and avoid walking too long.

3. Pay attention to the food.

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More other successful treatment cases for MS:

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