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Brief Summary: On June. 21, 2009, Dimitre from Bulgaria, who has suffered from MS, accompanied with the symptoms of the weakness and stiffness of the lower limbs for 9 years, the condition became worse in the latest 4 years, was hospitalized in our hospital. He has achieved significant improvement after 48 days TCM treatment here. The pains on the shoulders, neck, upper arms and waists disappeared. The problem of urinary incontinence was eliminated. The stiffness and weakness of the lower limbs have been improved obviously. At the same time, he could walk with the hands holding on the rail back-and-forth without the help of crutches. His weight also increased 7 kg.

 

                                                                                                                      Record of Hospitalization

Name: Dimitre                                                                                                       Birthplace: Bulgaria

Sex: Male                                                                                                              Profession: Businessman

Age: 41                                                                                                                 Date of Admission: June. 21, 2009

Nationality: Bulgaria                                                                                             Date of Record: June. 21, 2009

Marital Status: Married                                                                                       Onset Season: Beginning of Summer

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

 

                                                                                 First Medical Record

Date: June. 21, 2009                                         Time: 19: 00 p. m.

Dimitre, a 41-year-old male, has suffered from MS, accompanied with the weakness and stiffness of the lower limbs for 9 years. The condition became worse in the latest 4 years. He was hospitalized in our hospital for treatment on June. 21, 2009.

Essentials for Diagnosis:

1. The patient has suffered from the weakness and stiffness of the lower limbs for 9 years. The condition became worse in the latest 4 years.

2. The patient suffered stiffness and weakness of lower limbs without obvious reason in June, 2000. At that time, he paid no attention to it and did not take any examination or treatment. Then the condition became worse gradually. In 2002, he was examined by MRI at the local hospital (name unknown) and diagnosed as MS. The doctor told him there was no medical treatment but gave him interferon injection, one time per week and without other solution. In the recent 4 years, the condition became worse with the tight feeling of the lower limbs. The walking became very difficult for him. He can only walk slowly with the help of crutches for a short distance. As the activity of the lower limbs was not good, the joints were difficult to stretch and bend. He could not lift his legs. There was concave swelling symptom from the ankles to the back of the feet. To pursue improvement, he came to our hospital for the treatment on June. 21, 2009.

3. T 36.2¡æ, P 80 times/minute, R 20 times/minute, BP 100/60mmHg.

4. He grew normally with medium nutrition. His mind is conscious. He looked tired with a feeling of chronic illness.

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. The patient¡¯s lower limbs were weak and stiff for 9 years. The condition worsened in the latest 4 years with the tight feeling. His walking became very difficult. He can only walk slowly with the help of crutches for a short distance. As the activity of the lower limbs was not good, the joints were difficult to stretch or bend, he could not lift his legs. There was concave swelling symptom from the ankles to the back of the feet. The tongue body was reddish and purple with teeth marks on the margins of the tongue. His tongue coating was yellow and thin. His pulse was slippery. According to the symptoms of the tongue and pulse, he was diagnosed with wilting pattern.

7. Accessory examination: none.

Diagnostic Basis:

TCM: The patient has typical symptoms of the weakness and pains of the lower limbs for 9 years. The condition worsened in the latest 4 years with the tight feeling. His walking became very difficult. He can only walk slowly with the help of crutches for a short distance. As the activity of the lower limbs was not good, the joints were difficult to stretch or bend. He could not lift his legs. There was concave swelling symptom from the ankles to the back of the feet. The tongue body was reddish and purple with teeth marks on the margins of the tongue. His tongue coating was yellowish and thin. His pulse was slippery. According to the symptoms of the tongue and pulse, he was diagnosed with wilting pattern.  

Western Medicine: The patient¡¯s lower limbs were weak and stiff for 9 years. The condition worsened in the latest 4 years with the tight feeling. His walking became very difficult. He can only walk slowly with the help of crutches for a short distance. As the activity of the lower limbs was not good, the joints were difficult to stretch or bend. He could not lift his legs. There was concave swelling symptom from the ankles to the back of the feet. In 2002, he was diagnosed with MS.  

Diagnostic Differentiation:

TCM: The patient's wilting pattern should be differentiated from impediment pattern. Wilting pattern is mainly characterized by limp, emaciated sinews and bones, with weakness of the muscles. However, 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 (Traditional Chinese Medicine) diagnosis: Wilting pattern

Symptom identification: Yin vacuity of the liver and kidneys, obstruction of the channels and network channels due to heat-damp.

Western Medicine: Multiple Sclerosis (MS)

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Low-fat diet.

4. Acupuncture and massage: once a day.

5. Treatment strategy: clear heat and inhibit dampness, soothe the sinews and quicken the network channels, enrich and supplement the liver and kidneys.

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

Main herbs used in the herbal tea: chuanxiong (ligusticum root), honghua (carthamus flower), etc. 3 dosages in total.

7. Functional exercise for the lower limbs once a day.

 8. Have more medical examinations if necessary.

 

Date: June. 23, 2009                                          Time: 10: 00 a. m.

The examinations of the urination, excreta and blood were normal. The functions of the liver and kidneys were normal without exceptional discoveries. Since the hospitalization, the diet and sleeping of the patient were good. Except for the herbal tea, acupuncture and massage treatment, the patient should pay attention to the functional exercises and having a calm mind and confidence with the treatment.

 

Date: June. 25, 2009                                           Time: 10: 00 a. m.

The swelling of the patient¡¯s lower limbs and feet dorsa have disappeared gradually. His urine was of several times during the night. The prescription was changed a little. 5 dosages in total.

 

Date: June. 26, 2009                                            Time: 10: 00 a. m.

The patient said that the stiffness and weakness of the lower limbs were improved a little. He was happy that there was some improvement after 4 days herbal tea. He walked himself actively before the doctor. 

 

Date: June. 30, 2009                                             Time: 11: 00 a. m.

The patient said that the walking of the lower limbs were not so difficult than before. The frequency and urgency of the urine were better compared with before. He felt thirsty and drunk a lot. The tongue color was red. The tongue coating was yellowish. The swelling of the feet dorsa have vanished. 

 

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

The patient said he felt thirsty and uncomfortable on the pharynx part, stiffness of the arms and waists. The frequencies of the urination increased during the night and he had pains on the neck.   

 

Date: Jul. 11, 2009                                           Time: 10: 00 a. m.

The pains on the neck and waists were reduced. The frequency of the urination has also reduced. 5 dosages in total.

 

Date: Jul. 16, 2009                                           Time: 10: 00 a. m.

There were red rashes scattering on the whole body without itching and painful feeling. 5 dosages in total.

 

Date: Jul. 21, 2009                                           Time: 16: 00 p. m.

The stiffness and weakness of the lower limbs were improved obviously. He could walk around the rail. The former prescription was changed a little. 4 dosages in total.

 

Date: Jul. 26, 2009                                          Time: 11: 00 a. m.

The stiffness and weakness of the lower limbs, arms, waists and pelvis joints were improved significantly. The strength of the lower limbs was increased gradually with more exercises. The pains on waists disappeared. The aches on the neck were reduced. He had a good mood. 4 dosages in total.

 

Date: Jul. 31, 2009                                          Time: 10: 30 a. m.

Things were going well with the patient. The former prescription was changed a little.

 

Date: Aug. 5, 2009                                          Time: 10: 00 a. m.

The stiffness and weakness of the lower limbs were improved obviously with increasing strength. He could walk around the rail without the help of the crutches. There was still edema in the lower limbs but the blood stasis has disappeared totally. There was some improvement that his joints were able to stretch and bend. He could try to lift his legs. The frequency, urgency and lose of control of the urine have been improved obviously. The patient decided to go home, and he brought 46 days herbal tea with him to continue the treatment. He said he will come to our hospital for the comprehensive treatment again next year. The stiffness and pains of the neck have been away.    

 

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

He decided to leave the hospital tomorrow. Suffering from MS for 9 years, the patient has got good improvement generally after about 40 days treatment by herbal tea, massage and acupuncture. He was very pleased with the result. He walked upstairs from his room in the 3rd floor to the 5th floor and watched the process how to decoct the herbal tea so that he could decoct the herbal tea in a proper way. He will come for another 2 months¡¯ treatment here next year.

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