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Records of Hospitalization
Name: Vasal
Sex: Male
Age:
33 Profession: White-collar
Nationality:
Canada Marital status: Unmarried
Onset Season: Autumn
Date of Admission: Aug. 11th
2007
Complainer: The
patient¡¯s himself Reliability: Reliable
Major complaint: The
patient has suffered from trembling of his hands accompanied with walking
unsteadily for 6 years and has aggravated for 2 years.
Present illness:
In June of 1999, the patient suddenly felt unable to get up on time for work,
accompanied by numbness of his head with slight pain. At the time, the patient
went to a hospital of Canada¡¯s capital for a MRI examination, and he was
diagnosed with MS. The hospital advised him to accept Lihua
Intramuscular, and he got some
improvement. In Mar. of 2001, he began to feel trembling of his hands and
unsteadily walking, accompanied by muscular relaxation of his limbs and muscular
atrophy of his palms¡¯ hukou. He felt the trembling of his hands and weakness all
over his body. His sight declined progressively. Through the suggestions of the
internet Professors of American and Canada, he was also given
Lihua
Intramuscular, but there was still
no obvious improvement. What¡¯s worse, his symptoms aggravated progressively. The
present symptoms: he was suffering from the trembling of his hands and
unsteadily walking, accompanied by muscular relaxation of his limbs and muscular
atrophy of his palms¡¯ hukou. He felt weak all over the body with poor balance.
He could walk with the support of other people or a crutch. No symptoms of
dizziness, nausea, vomiting,
fever or aversion to coldness. His spirit was normal, with small quality of diet
and sleep. He had one stool every 3 to 5 days. His urination was frequent with
three times at night. His tongue was red with white and thin tongue coating. His
pulse was weak and fine.
Disease history: he has
been health all the time. No history of tuberculosis, hepatitis, or other
infectious diseases. No allergic history of medicine. No history of preventive
vaccination. With the trauma for his right hand¡¯s rib. No history of blood
transfusion.
Personal history: he was
born in Canada, living in a normal environment. No contact history of
schistosomiasis. With light diet. He had the hobby of drinking but now stopped.
Marital history: he was
unmarried.
Family history: His
parents were both healthy. No family history of
inherited disease.
Physical examination:
T 36.2¡æ£¬P
84 bpm, R 18 bpm, BP 110/70mmHg
He was
mid-nourished and normally developed. His mind was clear. He was in a positive
position and cooperative in examination. No jaundice in the sclera. No
superficial lymph-node enlargement.
No deformity of skull and the five
sense organs. He was with
sparse hair and pale face. Bilateral pupils were round and equal in size and
sensitive to light. His nose was without any sinking or purulence. The ears look
normal in appearance
with no purulence. His month was
dry. No congestion in
throat. No enlargement of
his tonsils. With soft neck
and trachea placed in the middle. No enlargement
of the thyroid gland. No varicose jugular vein.
No thoracic deformity. Sound of
breath was bilaterally normal on auscultation. No respiratory rales or pleural
friction rubs. No apophysis of the precordial region. Heart border was normal.
Heart beat 80 times/min. Cardiac rhythm was regular. No pathological murmurs on
auscultation. Abdomen touched flat and soft
without tenderness or rebound tenderness. Liver and spleen were not palpable. No
percussion pain in renal region. Bowel sound was normal. No spinal and pelvic
deformity. No deformity or inflexibility of his limbs. His tongue was red
with white and thin tongue coating. His pulse was weak and fine.
The
specific condition: he was suffering from the trembling of his hands, especially
worse in his left hand. He could not hold pens to write. The experiment to his
hands was (+). His lower limbs were with poor balance. He was weak with the
support of crutch. The knees joints were stiff.
The muscle strength was Grade
¢ó
with decreasing muscle tension.
Diagnostic examination: In June of 1999, after the examination of MRI, he was
diagnosed with MS in a capital hospital of his own country.
First
diagnosis:
TCM
diagnosis: Chan-syndrome (Trembling syndrome)
Symptom diagnosis: Deficiency of the liver and kidneys, accompanied with
Liver-wind entering the vessels.
WM
diagnosis: Multiple sclerosis (MS)
First
Medical Record
Aug. 11th 2007
Vasal,
a 33-year-old male, has suffered from trembling of his hands and walking
unsteadily for 6 years and has aggravated for 2 years. He was picked up by our
staff at Zhijiang Airport and arrived in Huaihua Red Cross Hospital for further
treatment at 19: 40 p.m. Aug. 11th 2007.
Essentials for diagnosis:
1. The
patient has suffered from trembling of his hands and walking unsteadily for 6
years and has aggravated for 2 years.
2. In June of 1999, the patient
suddenly felt unable to get up on time to work, accompanied by numbness of his
head with slight pain. At the time, the patient went to a hospital of Canada¡¯s
capital for a MRI examination, and he was diagnosed with MS. The hospital
advised him to accept Lihua
Intramuscular, and he got some improvement. In Mar. of 2001, he began to feel
trembling of his hands and unsteadily walking, accompanied by muscular
relaxation of his limbs and muscular atrophy of his palms¡¯ hukou. He felt the
trembling of his hands and weakness all over his body. His sight declined
progressively. Through the suggestions of the internet Professors of American
and Canada, he was also given
Lihua
Intramuscular, but there was still
no obvious improvement. What¡¯s worse, his symptoms aggravated progressively. The
present symptoms: he was suffering from the trembling of his hands and
unsteadily walking, accompanied by muscular relaxation of his limbs and muscular
atrophy of his palms¡¯ hukou. He felt weak all over the body with poor balance.
He could walk with the support of other people or a crutch. No symptoms of
dizziness, nausea, vomiting,
fever or aversion to coldness. His spirit was normal, with small quality of diet
and sleep. He is constipated. He had bowel movement every 3 to 5 days. His
urination was frequent but
disability to urinate. His
tongue was red with white and thin tongue coating. His pulse was weak and fine.
3. T
36.2¡æ£¬P
84 bpm, R 18 bpm, BP 110/70mmHg
4. He
was mid-nourished and normally developed. His mind was clear. He was in a
positive position and cooperative in examination.
5. No
thoracic deformity. Chest percussion noted resonance. Sound of breath is
bilaterally clear on auscultation. No sound of pleural friction.
6.
Diagnostic examination: In June of 1999, after the examination of MRI, he was
diagnosed with MS in a capital hospital of his own country.
Diagnostic basis
TCM:
The patient has suffered from trembling of his hands and walking unsteadily for
6 years. It belongs to vacuity of liver-kidneys and blood-essence, so it could
not nourish the sinews and vessels. The qi-blood runs sluggishly, which leads to
the muscles trembling. The liver is in charge of sinews, which is the viscus of
wind and wood. Liver-wind enters the vessels, so the sinews and vessels could
not be in charge. Since the deficiency of liver and kidneys, he suffered from
frequent urination. Long disease could hurt the blood-qi, which leads to
weakness all over the body. His tongue was red with white and thin tongue
coating. His pulse was weak and fine.
Western medicine:
1. The
patient has suffered from trembling of his hands and walking unsteadily for 6
years, accompanied by weakness all over his body.
2.
His legs could raise 40 degrees. The reflection of knees was
hyperthyroidism. The Babinski levy
also was (+). The keens¡¯ joints were stiff.
3.
In June of 1999, after the examination of MRI, he was diagnosed with MS.
4.
His
muscular tension decreased
with Grade
¢ó
muscle strength. The experiment to his
hands was (+).
Diagnostic differentiation
TCM:
The patient¡¯s
Chan-syndrome should be differentiated from spasm. Spasm is particularly
prevalent in the attack¡¯s period of acute fever or chronic disease. Spasm is
more often in durative, sometimes with intermittence. The movement of his hands
and feet was not very flexible. Some patients have the symptoms of fever,
showing the whites of eyes, and dizzy spirit. While Chan syndrome is a kind of
chronic disease, with the main symptoms of uncontrollable trembling in the parts
of head, neck, hands and feet. The range of trembling is small, and the
frequency is very fast. It is not difficult to be distinguished with the
symptoms of muscular spasm, fever and dizzy spirit.
WM:
Chan-syndrome should be differentiated from sequelae of cerebral hemorrhage.
Sequelae of Cerebral hemorrhage are particularly prevalent in the elderly, often
leading to part of the body dysfunction. The lesion part is the brain vascular.
While multiple sclerosis is a nervous system of chronic disease that impacts the
central nervous system (brain, nerve and spinal cord), which causes visual
impairment completely, ataxia, unclear speech, tremor, limb numbness, weakness,
or even hemiplegia. They are not difficult to be distinguished with the
pathogeneses and conditions of disease.
First diagnosis:
TCM
diagnosis: Chan-Syndrome
(Tremor syndrome)
Symptom diagnosis:
Deficiency of the liver and kidneys, accompanied with Liver-wind entering the
vessels.
WM
diagnosis: MS
Plans
for treatment strategy and nursing
1. On
routine care of traditional Chinese internal medicine
2. On
grade II care
3.
Regular diet
4.
Herbal tea (to enrich and nourish the liver and kidneys, to extinguish wind and
check tetany): one dosage a day and drink twice
Main
herbs in five dosages herbal tea: Baishu (Ovate Atractylodes root), Shengqi
(Fresh Astragalus root), Fuling (Poria), etc.
6.
Acupuncture and massage: once a day
7.
Take 20-minute exercise every day for the function of his limbs
8.
Have more medical examinations if necessary
Date:
Aug. 12th 2007 Time: 10:30 a.m.
Today
the patient complained to Dr. Yan that he was suffering from his hands¡¯
trembling and unsteadily walking. The examination to the blood, bowel movement
and urination were all normal. The examination to the function of his liver and
kidneys were both normal. The electrolyte examination was also normal.
Examination: T 36.2¡æ£¬P
84 bpm, R 18 bpm, BP 110/70mmHg.
His heart and lung were normal, and his abdomen was soft and flat.
Doctor Yan¡¯s analysis:
1. The
patient has suffered from trembling of his hands and walking unsteadily for 6
years and has aggravated for 2 years.
2.
He was suffering from the trembling of his
hands, especially worse in his left hand. He could not hold pens to write. The
experiment to his hands was (+). His lower limbs were with poor balance. He had
difficulty in walking and could walk slowly about 10 to 15 meters with the
support of crutch. His lower limbs were weak and limp with stiff knees¡¯ joints.
The muscle strength of his limbs was Grade
¢ó with decreasing muscle tension.
3. In June of 1999, after the
examination of MRI, he was diagnosed with MS in a local hospital.
According to the above information,
TCM considered it as Chan-syndrome (Tremor syndrome). Dr. Yan analyzed it was
owing to deficiency of the liver and kidneys, accompanied with Liver-wind
entering the vessels.
Principle of TCM treatment:
fortifying the spleen and boosting
qi, enriching liver and supplementing the kidneys, extinguishing wind and
checking tetany. Herbal tea prescribed for five days including Baishu (Ovate
atractylodes root), Shengqi (Fresh Astragalus root), Fuling (Poria), etc.One
dosage a day and drink twice.
Prescription: Variable in Extinguishing-Wind and Checking-Etany Decoction
Doctor¡¯s requirement: take five dosages of herbal tea of the same prescription.
Acupuncture and massage for once a day. The patient will have more medical
examinations if necessary.
Date:
Aug. 13th 2007 Time: 9:30 a.m.
The
patient did not complain about any other special discomfort and still felt his
hands¡¯ trembling with unsteadily walking. The ECG examination was normal, and
the examination of B-ultrasomotonography to liver, kidneys, ureter, bladder and
prostate was also normal.
His heart and lung were normal, and his abdomen was soft and flat. His spirit
and appetite were normal, and his sleep was food. His bowel movement and
urination were both normal.
His tongue was red with white and thin tongue coating. His pulse was weak and
fine. Doctor¡¯s requirement: The herbal tea should follow the original
formulation.
Date:
Aug. 14th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking was also
getting better. His heart
and lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Aug. 18th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking was also
improving. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Aug. 22nd 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Aug. 26th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: take five dosages herbal tea of the former prescription.
Date:
Aug. 30th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Sep. 4th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Sep. 9th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: take five dosages herbal tea of the former prescription.
Date:
Sep. 14th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Sep. 20th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Sep. 25th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Sep. 30th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: take five dosages herbal tea of the former prescription.
Date:
Oct. 5th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Oct. 10th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Oct. 15th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Oct. 20th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: take five dosages herbal tea of the former prescription.
Date:
Oct. 25th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Oct. 30th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteadily walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement: The herbal tea should follow the original formulation.
Date:
Nov. 2nd 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling got some improvement. His unsteadily walking improved significantly
than before. His heart and lung were normal, and his abdomen was soft and flat.
His spirit and appetite were normal, and his sleep was food. His bowel movement
and urination were both normal. His tongue was red with white and thin tongue
coating. His pulse was weak and fine. The patient demanded to leave the hospital
today.
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