Brief Summary:
On January 17, 2010, Kamal from Bahrain, who has suffered from
MS, was hospitalized in our hospital. He had weakness of the
lower limbs for 15 years. Besides, he had incontinence of urine
for 5 years. After 56 days treatment here, he had got much
improvement.
Record of Hospitalization
Name:
Kamal
Birthplace: Bahrain
Sex: Male
Profession: Business man
Age: 49
Date of Admission: January 17, 2010
Religion: Muslim
Date of Record: January 17, 2010
Marital Status: Married
Onset Season: Heavy Snow
Complainer: The patient himself. The case was recorded by TCM
group.
First Medical Record
Date: January 17, 2010
Time: 19: 30 p. m.
Kamal, a 49-year-old male, who has suffered from MS, was
hospitalized in our hospital on
January 17, 2010.
Essentials for Diagnosis:
1. The patient has
suffered from weakness of the lower limbs for 15 years. Besides,
he had incontinence of urine for 5 years.
2. The patient
began to feel weakness of the lower limbs and the blurred vision
of the left eye without obvious reason. Besides, he had
incontinence of urine for 5 years. Then he went to a local
hospital and he was given MRI examination. He was diagnosed with
MS. He was given a certain kind of injection called "interferon
inducer", three times for each week. However, he did not get
obvious improvement after five year's treatment. In January of
2010, he stopped his previous treatment. At that time, he could
not walk by himself because of the weakness of the lower limbs.
To pursue the comprehensive treatment, on
January 17, 2010, he came to our hospital.
3. T 36.3≧,
R 20 times/minute, P 80 times/minute, BP 120/80mmHg.
4. He grew normally
with excessive nutrition. His mind was clear. He had an
expression of chronic illness and tiredness. His 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 80 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 weakness of the lower limbs for
15 years. He had blurred vision of left eye. Besides, he had
incontinence of urine for 5 years. He went to a local hospital
and he was given MRI examination. He was diagnosed with MS. Then
he was given a certain kind of injection called "interferon
inducer", three times for each week. However, he did not get
obvious improvement after five year's treatment. His 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. He got much improvement after his treatment
here. His tongue was pale. His tongue
coating was thin and slight white. His pulse was wiry and
thready. According to the symptoms of the tongue and
pulse, he was diagnosed with impediment pattern.
Western Medicine: The patient has suffered from the symptom of
the weakness of the lower limbs for 15 years. He had blurred
vision of left eye. Besides, he had incontinence of urine for 5
years. In 1995, he was diagnosed with MS by MRI in his local
hospital.
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, sinews
and vessels deprived of nourishment.
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. Common food.
5. TCM treatment
strategy: enrich the liver and the kidneys, soothe the sinews
and free the network vessels.
6. Herbal tea: one
dosage a day and drink twice.
7. Acupuncture and
massage: once a day.
8. Have more
medical examinations if necessary.
Date: January 18, 2010
Time: 11: 00 a. m.
The patient had
weakness of his both lower limbs. And he had had difficulty in
walking. Then he came to our hospital on January 17, 2010 for
comprehensive treatment. From the idea of TCM (Traditional
Chinese Medicine), his condition was due to sinews and vessels
deprived of nourishment, vacuity of the liver and kidneys. Then
our strategy was to soothe the sinews and free the network
vessels and enrich the liver and the kidneys. So our expert team
prescribed a special formula for him.
Date:
January 21, 2010
Time: 10: 00 a. m.
The patient¨s condition was the same and had no obvious
improvement. His tongue was pale. His tongue coating was thin
and slight white. His pulse was wiry and thready. Then we
changed the formula a little for the first time.
Date:
January 26, 2010
Time: 10: 00 a. m.
The patient could feel the strength of the lower limbs. Besides,
his incontinence of urine had got some improvement. His spirit
was good as well as his appetite. However, he had stinging pains
of the left sole sometimes. According to his latest condition,
we prepared a new formula again for the second time.
Date: February 1, 2010
Time: 10: 00 a. m.
The patient felt good. He could feel more strength of his two
lower limbs. Besides, the condition of the stinging pains had
got much improvement. He had no incontinence of urine in recent
days. The tongue body was dark red. Then he was told to continue
to use the above formula to consolidate the result.
Date: February 6, 2010
Time: 10: 00 a. m.
The patient's feedback was good. He can walk by himself by the
help of holding something. However, his blurred vision had no
obvious improvement. Then we changed his above formula a little.
Date:
February 11, 2010
Time: 10: 00 a. m.
The patient's spirit, appetite and sleeping were in normal
condition. At the same time, his walking had got much
improvement. He told us that he could walk about 100 meters by
the help of holding something. His blood pressure was normal.
Then we changed his formula a little for the second time to let
him get further progress.
Date:
February 21, 2010
Time: 10: 00 a. m.
The patient's condition was stable. So he was told to use the
same formula to consolidate the result.
Date:
February 26, 2010
Time: 10: 00 a. m.
The patient told us that his spirit was very good. His strength
of the lower limbs had increased by 5%. His tongue body was red.
So he continued to take the same formula.
Date:
March 1, 2010
Time: 10: 00 a. m.
The patient's condition was good. He also felt very well. So he
still used the above formula.
Date:
March 6, 2010
Time: 10: 00 a. m.
The patient's spirit was good as well as his appetite and sleep.
The most important thing was that, the patient could stand up by
himself in recent four days.
Date:
March 6, 2010
Time: 10: 00 a. m.
The patient said that everything was going smoothly these days.
His condition was stable. He felt very satisfied with the
improvement.
Date:
March 14, 2010
Time: 10: 00 a. m.
Compared with before, his condition got obvious improvement.
After 56 days of comprehensive treatment here including herbal tea,
massage and acupuncture, the symptoms improved a lot. He could stand up
by himself. His spirit, appetite and sleeping were OK.
The patient decided to leave the
hospital tomorrow.
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