2010, Pauline from Canada, who has suffered from ALS. She is still living in Canada in 2019.
On June 24, 2010, Pauline from Canada, who has suffered from ALS, was hospitalized in our hospital. She has had the weakness of her four limbs for one and half a year and accompanied with the muscle atrophy for 8 months. After five months treatment, she achieved a good result.
Record of Hospitalization
Name: Pauline Birthplace: Canada
Sex: Female Profession: Web worker
Age: 43 Date of Admission: June 24, 2010
Marital Status: Married Date of Record: June 25, 2010
Nationality: Canada Onset Season: Summer Solstice
Major Complaints: She has had the weakness of her four limbs for one and half a year and accompanied with the muscle atrophy for 8 months.
Present Illness: The patient found the obvious weakness on the left lower limb at the beginning of 2008. Then this problem affected the four limbs and muscle atrophy appeared. The local doctor diagnosed it as ALS. The patient has received the acupuncture, but the treatment effect was not so good. Now, she has the weakness of her four limbs and atrophy on the part of the hand between the thumb and the index finger. The muscles of the other parts are relaxant but not apparently atrophic. She has no problem of walking, but the long time walking will cause pains in the buttocks. She has normal spirit but is easy to get tired. Both of her sleep and appetite is good. Her swallowing and urination is normal and stool is loose. Also, she has muscle jumpings, but it is not very obvious.
Disease History : Between 1983 and 1986, she had the mild enlarged thyroid. After the treatment, it has recovered now. In 1986, she had the ulcerative colitis and take medicine until 1991. She has no tuberculosis, typhoid and hepatitis. She is not allergic to any food but allergic to erythrocin. She has no history of blood transfusion.
Personal History: She was born in Canada. No contact history of schistosomiasis. No addiction to smoking and alcohol. She has a even temper but much working pressure. Marriage History: She get married and has two children and a healthy husband. Family History: No family members got the similar disease before. Physical Examination T: 37.1℃ P: 80bpm R: 20bpm BP: 100/60mmHg
She was mid-nourished and normally developed. Her mild was clear. Her skin was moist. Her neck was soft and trachea is in the midline. No jaundice in the sclera. No superficial lymph-node enlargement. No enlarged thyroid. Sound of breath was bilaterally normal on auscultation. Heart border was normal. Heart beat 80/min. Cardiac rhythm was regular. No pathological murmurs on auscultation. Abdomen was flat and soft without tenderness or rebound tenderness. Liver and spleen were not palpable. Her four limbs are very weak, especially the upper limbs. Muscles are atrophic on the part of the hand between the thumb and the index finger. At the same time, she can not abduce her thumbs completely. The other parts muscles are relaxant but not apparently atrophic. She had the left foot drop. The movement of the joints is normal. No check of her anus and the two lower orifices. She has dark tongue body and whitish, thick tongue coating and weak pulse..
First Diagnosis: TCM diagnosis: Wei-syndrome (flaccidity syndrome) Symptom Diagnosis: Yin blood deficiency, tendon and vessel malnutrition. Western medicine diagnosis: ALS Diagnosis Basis: TCM： Wei-syndrome (flaccidity syndrome) refers to the softness of the muscles and bones, and weakness of the limbs. Western medicine: The patients who get MS will get much more weaker after exercises, but after a short time rest, the symptom will be reduced. Also, compared to ALS, it is rare to see the muscle jumping, no pseudohypertrophy. Plan of treatment and care 1. On routine care of traditional Chinese internal medicine 2. On grade Two care 3. Under care of a companion 4. Low-fat protein diet 5. Pathogenesis: Yin blood deficiency, tendon and vessel malnutrition 6. Therapeutic Principle: Nourishing qi and blood, clear the meridians 7. Herbal tea: One dosage a day and drink twice, each time 180ml 8. Acupuncture and massage: Once a day 9. Have more medical examinations if necessary Date: June 26, 2010 Time: 10:00 a.m.
The patient has had the weak limbs for one and half a year, and muscle atrophy for 8 months. The local doctor diagnosed it as ALS. The patient has received the acupuncture, but the treatment effect was not so good. Now, she has the weakness of her four limbs and atrophy on the part of the hand between the thumb and the index finger. The muscles of the other partsare relaxant but not apparently atrophic. She has no problem of walking, but the long time walking will cause pains in the buttocks. She has normal spirit but is easy to get tired. Both of her sleep and appetite is good. Her swallowing and urination is normal and stool is loose. Also, she has the muscle jumpings, but it is not very obvious. She has dark tongue body and whitish, thick tongue coating and weak pulse. According to her pulse and tongue, professor Yang thought patient got wei-syndrome (flaccidity syndrome). The symptom was yin blood deficiency, tendon and vessel malnutrition.
Date: June 27, 2010 Time: 10:00 a.m. We got the results of the patient's body check. It was, HGB=1838/L, RBC 6.28/L HCT 55.1 PDW 14.5 Routine urinalysis: normal liver kidney function: normal Date: July 1, 2010 Time: 10:00 a.m. The patient was in stable condition, and she found that muscle jumpings reduced slightly. Tongue was a little dark, tongue coating was whitish and thin. She had menstruation yesterday, but menstrual quantity was less. Patient had no pains in waist, abdomen, and chest. So we decide to change the formula by taking away Eupatorium, adding yimucao to promote blood circulation by removing blood stasis. 5 dosages in all. Date: July 6, 2010 Time: 10:00 a.m. The patient had had stopped menstruation yesterday. The quantity was a little. She had no power of her thumbs, especially the left one. The muscle jumpings on the lower limbs reduced, but more appeared on the back. So we decide to change the formula to achieve the aim of nourishing yin and moving away fire in the body. 5 dosages in all. Date: July 11, 2010 Time: 10:00 a.m. The patient had less muscle jumpings and a litter more power of her lower limbs. Also, the left foot drop was a litter better. But, she still felt the power of her thumbs not strong enough. She could not hold the heavy things ,hooked deftly and open the door with the key. So, we take the method of nourishing yin blood and moving away fire in body as her therapeutic principles. 5 dosages in all. Date: July 16, 2010 Time: 10:00 a.m. Except no big improvement of muscle jumpings, the patient was in a stable condition. Today , she had light reddish tongue nature and thin-whitish tongue coating. Her pulse was a litter weak and the shape of pulse was not clear. So, we take the method of nourishing yin blood and moving away fire in body as her therapeutic principles. 5 dosages in all. Date: July 21, 2010 Time: 10:00 a.m. The patient had no obvious change of muscle jumpings. She felt a litter uncomfortable after drinking herbal tea in recent two days. So, we decided to nourish yin, move away fire in body and regulate qi and the stomach to solve this problem. 5 dosages in all. Date: July 26, 2010 Time: 10:00 a.m. After the treatment of supplementing qi and nourishing yin, the patient found that a little improvement of the power of her four limbs. At the same time, the muscle jumpings on arms, legs and back were reduced. Her current symptoms are weakness of the limbs, especially the thumbs; the left crus was fatigued and weak; no good sleep recent days, dark red tongue body, thin tongue coating and weak pulse. So, we decide to take the method of supplementing qi and nourishing yin, nourishing the heart to recuperate her body. Date: August 1, 2010 Time: 10:00 a.m. The patient had had her menstruation since July 29.The volume, color, or quality were good. She felt aching pains on her waist because that yesterday they moved house from our old hospital to our new hospital. So we decide to change the formula to strength the loins and invigorate the kidneys and promote the qi circulation and relieve pains. 5 dosages in all. Date: August 6, 2010 Time: 10:00 a.m. The patient stopped her menstruation on August 3. The period was shorter than last time. She still had muscle jumpings. But, it was much less than before. The power of the limbs was a little improved. The aching pains on the waist have gone. Sleep and defecation were normal. She had light nature body and whitish-thin tongue coating. Her pulse was slightly slow. So, we take the method of nourishing yin blood and moving away fire in the body as her therapeutic principles. 5 dosages in all. Date: August 11, 2010 Time: 10:00 a.m. The last few days, the patient found that the frequent muscle jumpings on the quadriceps of the right upper arm and lower limbs appeared again. The power of her four limbs was ok. But, her left foot was still dropping. The way of her walking was a little better than before. Her sleep and defecation were normal. She had light tongue body and whitish-thin tongue coating. Her pulse was fine slow. Because that the effect of formula was not so good, we decided to continue taking the prescription of August 6 which used the method of nourishing yin blood and moving away fire in the body as her therapeutic principles. 5 dosages in all. Date: August 11, 2010 Time: 10:00 a.m. The frequency of her muscle jumpings were reduced but the intensity was increased. Today, her tongue body was slightly reddish, tongue coating was thin and greasy. we decided to continue taking the method of nourishing yin blood and moving away fire in the body as her therapeutic principles. 5 dosages in all. Date: August 26, 2010 Time: 10:00 a.m. The frequency of her muscle jumpings were reduced greatly. Now, the major area of muscle jumpings focused on the quadriceps of the slightly pale thigh. The power of her four limbs was ok. Sleep and defecation were normal. She had slightly pale tongue body and whitish-thin tongue coating. Her pulse was slightly slow. So we decide to change the formula to achieve the aim of nourishing Yin and promoting blood circulation. 5 dosages in all. Date: September 1, 2010 Time: 10:00 a.m. The patient's muscle jumpings were remitted, but the power of her right upper limb was a little worse than before. Her spirit was good. Sleep and defecation were normal. She had slightly pale tongue body and whitish-thin tongue coating. Her pulse was slightly slow. So we decide to change the formula to achieve the aim of nourishing the kidneys and liver, nourishing Yin and generating body fluid. 5 dosages in all. Date: September 6 2010 Time: 10:00 a.m. The patient had cramps on her gastrocnemius during night. So we decide to change the formula to achieve the aim of enhancing the blood circulation. 5 dosages in all. Date: September 11 2010 Time: 10:00 a.m. Both of the intensity and frequency of her muscle jumpings were reduced greatly. Now, the major area of muscle jumpings focused on the quadriceps of thigh. Her sleep and defecation were normal. She had slightly tongue body and whitish-thin tongue coating. Her pulse was fine slow. We decided to change the formula to achieve the aim of strengthening the power of the limbs. 5 dosages in all. Date: September 16 2010 Time: 10:00 a.m. It is the 84th day the patient stayed in our hospital. Her current symptoms are: The left foot drop and the way of her walking was a little better than before. The power of her lower limbs was slightly improved. The spirit was getting better, and the fatigue disappeared. The muscle jumpings were under control but not stable. Sometimes, the muscle jumpings appeared on some parts of her body, but sometimes it appeared on the whole body. The patient got more power of her upper limbs during the first month after she came to our hospital, but lost some strength during the last 20 days and she also felt her upper limbs weak. She had no dramatic loss of weight. Her appetite, sleep and defecations was normal. She had slightly pale tongue body and whitish-thin tongue coating. Her pulse was slightly slow. Also, her pulse was better than before. Because no obvious effect during the last 20 days, we made a analysis for her. We got the idea: The liver govern the limbs, if the liver qi is weak, the pulse will be weak. The problem of weakness of the limbs and muscle jumping was caused by the liver wind agitation. So, we take the method of fortifying the spleen and supplementing Qi, softening liver and dispersing wind, promoting blood circulation and removing obstruction in the channels as her therapeutic principles. Date: September 21 2010 Time: 10:00 a.m. The patient had less muscle jumpings, and either the intensity or the frequency of her muscle jumpings were reduced. Now, the major area of her muscle jumpings appeared on the front of her thighs. She still had the muscle jumpings on her arms and back. Date: September 26 2010 Time: 10:00 a.m. With the weather get colder, the patient found that muscle jumpings increased a little bit. There was no obvious improvement of her upper limbs. She had slightly pale tongue body and whitish-thin tongue coating today. Her pulse was slightly slow. Date: October 1 2010 Time: 10:00 a.m.
After 3 months treatment, the patient had had a big improvement of her spirit. The lower limbs got more strength. Even after 30 minutes cycling exercises she did not feel tired. The problem of her left foot drop was almost gone. Her muscle jumpings were getting less, but the upper limbs were still weak. The muscles on the thenar, hypothenar and the thumb and index finger at the middle of the Tucks muscle was very relaxed. Her pulse was still very weak, especially the right pulse. According to the theory of TCM, weak limbs and right pulse are resulted from the deficiency of qi in middle-jiao. So, we decided to supply more qi in the middle-warmer for the patient.
Date: October 6 2010 Time: 10:00 a.m. The patient had good spirit and ruddy and luster complexion. Her hands got more power now. The grasping power of right hand was 15.5kg, left was 13.9kg. The patient still had muscle jumpings on the thighs and abdomen. Her tongue body was slightly reddish, coating was whitish and thin. The power of her pulse was a little better than before, especially the right one. So, we decided to add some rhizoma gastrodiae to calm wind and stop spasm. Date: October 9 2010 Time: 10:00 a.m. The patient had normal spirit, sleep, appetite and defecations. Her four limbs got more power and muscle jumpings were reduced. Today, she is going to Tibet for traveling with her family. We wish her good luck. Date: November 3, 2010 Time: 10:00 a.m. The patient returned from her traveling yesterday. She was absent for 24 days. Now, she had good spirit, sleep, appetite and defecations. She had slight muscle jumpings. However, her grasping power was a little decreased. Today, the test result was: right hand 15.0kg, left hand 12.6kg. She had slightly reddish tongue body and whitish tongue coating and weak pulse today. So, we decided to change her prescription to strengthen her sinews and bones. 3 dosages in all. Date: November 6, 2010 Time: 10:00 a.m. The patient was in a stable condition. She had slightly reddish tongue body, a little yellowish and thick tongue coating, and weak pulse. So, we decided to reduce her phlegm and smooth the veins. 5 dosages in all. Date: November 11, 2010 Time: 10:00 a.m. Since the patient coming back from her traveling, the whole situation of the patient was not as good as before, it was a little down. The power of her two hands was a little decreased. She had more muscle jumpings on her back and abdomen, but she was normal in her spirit, sleep and defecations. She had slightly reddish tongue body, a little yellowish and thick tongue coating, and weak pulse. It due to travel fatigue. So, we decided to invigorate the kidneys and strengthen muscle and bone. 5 dosages in all. Date: November 16, 2010 Time: 10:00 a.m. Now, the patient she can do something like holding knife and fork and, buttoning up much better than before. The muscle jumpings were reduced and she was in a stable condition. Date: November 16, 2010 Time: 10:00 a.m.