Brief Summary: On October 5, 2009, Rodica from Romania, who has suffered from MS, accompanied with the symptom of the weakness and pains of the lower limbs for 2 years, was hospitalized in our hospital. Her right hand was numb with the sense of electric current. She sweated easily and felt depression. She came to our hospital for the treatment from January 20 to March 3 in 2009. The record of her hospitalization was 2009002. So this was her second visiting to our hospital. She has achieved much improvement after 36 days TCM treatment here. Compared with before, her condition was normal and good. There was no numbness in the right hand.

 

Record of Hospitalization

Name: Rodica                                                                                                     Birthplace: Romania

Sex: Female                                                                                                        Profession: Doctor

Age: 53                                                                                                               Date of Admission: October 5, 2009

Religion: Romanians                                                                                           Date of Record: October 5, 2009

Marital Status: Married                                                                                     Onset Season: Heavy Snow

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

 

First Medical Record

Date: October 5, 2009                                       Time: 19: 30 p. m.

Rodica, a 53-year-old female, has suffered from MS, accompanied with the symptom of the weakness and pains of the lower limbs for 2 years. She was hospitalized in our hospital at 19: 30 a. m. on October 5, 2009.

Essentials for Diagnosis:

1. The patient has suffered from the symptom of the weakness and pains of the lower limbs for 2 years.

2. The patient began to feel the stinging pains of the heel and joints on the right foot without obvious reasons in 2 years ago. Also there were numbness and pains of the wrist and fingers in the right hand. In 2008, she was given MRI examination in the local hospital with white matter lesions and was diagnosed with MS. She came to our hospital for the treatment during January 20 to March 3 in 2009. The record of her hospitalization was 2009002. At that time, she was diagnosed as impediment pattern. Her 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. She got much improvement after her treatment here. And she brought herbal tea back home for the further treatment. In this way, she got continuing improvement. Because the condition of her thyroid was not normal before; and the figure of the T3, T4 were high. But the thyroid condition went back to normal after taking the herbal tea. To strengthen the treatment result, she came to our hospital again. Now, her general condition was good, but for the numbness and pains of the right hand was numb with the sense of electric current. She sweated easily and felt depression.

3. T 36.6≧, R 20 times/minute, P 78 times/minute, BP 120/80mmHg.

4. She grew normally with excessive nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. Her 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 78 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 the weakness and pains of the lower limbs for 2 years. She began to feel the stinging pains of the heel and joints on the right foot without obvious reasons in 2 years ago. Also there were numbness and pains of the wrist and fingers in the right hand. In 2008, she was given MRI examination in the local hospital with white matter lesions and was diagnosed with MS. She came to our hospital for the treatment during January 20 to March 3 in 2009. The record of her hospitalization was 2009002. At that time, she was diagnosed as impediment pattern. Her 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. She got much improvement after her treatment here. And she brought herbal tea back home for the further treatment. In this way, she got continuing improvement. Because the condition of her thyroid was not normal before; and the figure of the T3, T4 were high. But the thyroid condition went back to normal after taking the herbal tea. To strengthen the treatment result, she came to our hospital again. Now, her general condition was good, but for the numbness and pains of the right hand was numb with the sense of electric current. She sweated easily and felt depression. Also there was slight fatty liver with her. Her tongue was pale. Her tongue coating was thin and slight white. Her pulse was wiry and thready. According to the symptoms of the tongue and pulse, she was diagnosed with impediment pattern. Professor Yang believed that her case was due to vacuity of the liver and kidneys, depression of the liver, qi stagnation and blood stasis. So the treatment strategy is to supplement and boost the liver and kidneys, move qi and quicken the blood circulation, course the liver and resolve depression.

Western Medicine:  The patient has suffered from the symptom of the weakness and pains of the lower limbs for 2 years. She began to feel the stinging pains of the heel and joints on the right foot without obvious reasons in 2 years ago. Also there were numbness and pains of the wrist and fingers in the right hand. In 2008, she was given MRI examination in the local hospital with white matter lesions and was diagnosed with MS.

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, depression of the liver, qi stagnation and blood stasis.

Western Medicine diagnosis: MS

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade  = 3 \* ROMAN III care.

3. Under the care of a companion.

4. Low-fat diet.

5. TCM treatment strategy: supplement and boost the liver and kidneys, move qi and quicken the blood circulation, course the liver and resolve depression.

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

7. Acupuncture and massage: once a day. 

 

Date: October 6, 2009                                       Time: 10: 00 a. m.

The patient has suffered from the symptom of the weakness and pains of the lower limbs for 2 years. She began to feel the stinging pains of the heel and joints on the right foot without obvious reasons in 2 years ago. Also there were numbness and pains of the wrist and fingers in the right hand. In 2008, she was given MRI examination in the local hospital with white matter lesions and was diagnosed with MS. She came to our hospital for the treatment during January 20 to March 3 in 2009. The record of her hospitalization was 2009002. At that time, she was diagnosed as impediment pattern. Her 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. She got much improvement after her treatment here. And she brought herbal tea back home for the further treatment. In this way, she got continuing improvement. Because the condition of her thyroid was not normal before; and the figure of the T3, T4 were high. But the thyroid condition went back to normal after taking the herbal tea. To strengthen the treatment result, she came to our hospital again. Now, her general condition was good, but for the numbness and pains of the right hand was numb with the sense of electric current. She sweated easily and felt depression. Also there was slight fatty liver with her. Her tongue was pale. Her tongue coating was thin and slight white. Her pulse was wiry and thready. According to the symptoms of the tongue and pulse, she was diagnosed with impediment pattern. Professor Yang believed that her case was due to vacuity of the liver and kidneys, depression of the liver, qi stagnation and blood stasis. So the treatment strategy is to supplement and boost the liver and kidneys, move qi and quicken the blood circulation, course the liver and resolve depression. The prescription was as follows: Rehanniae Radix Conquitum, Cornus, Tangkuei, Dioscorea etc. 5 dosages in total.

 

Date: October 7, 2009                                       Time: 10: 00 a. m.

The feedback of the prescription was good. Her condition was normal.

 

Date: October 10, 2009                                       Time: 10: 00 a. m.

Her general condition was normal. She complained lots of sweat. When she did some exercises, there were many sweats. Her urination and stool were normal. Her diet and sleeping were good. The former prescription was changed a little. 5 dosages in total.

 

Date: October 15, 2009                                       Time: 8: 40 a. m.

The patient's condition was stable. The prescription was the same as the one on October 10^th. 5 dosages in total.

 

Date: October 20, 2009                                       Time: 8: 40 a. m.

Her general condition was normal. Her urination and stool were normal. Her diet and sleeping were good. The prescription was not changed.

 

Date: October 25, 2009                                      Time: 8: 50 a. m.

The patient felt good. The prescription was the same. 5 dosages in total.

 

Date: October 31, 2009                                       Time: 8: 50 a. m.

The patient felt a little tired sometimes. Her sleeping was quiet. Her diet was normal. There was slight pain on the left side of the head. The prescription was changed a little. 5 dosages in total.

 

Date: Nov. 5, 2009                                       Time: 8: 40 a. m.

Her condition was stable. Continue to take the same prescription. 5 dosages in total.

 

Date: Nov. 9, 2009                                       Time: 10: 00 a. m.

There was obvious improvement of sweating. Her sleep was ok. Her urination and stool were normal. She has achieved much improvement after 36 days TCM treatment here. Compared with before, her condition was normal and good. There was no numbness in the right hand. The patient decided to leave the hospital tomorrow.

 

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