TCM China:  

Record of Herbal Treatment Of Fadwa from Jordan Improvement Of  MS
 

 

   

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, 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 patients 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 patients 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 didnt 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 didnt 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 didnt 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 didnt 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.

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