2014, Alsalahi, from Yemen, who had suffered from movement limitation over his left leg
On April 14, 2014, Alsalahi, from Yemen, who had suffered from movement limitation over his left leg, accompanied by slight muscle atrophy over his left leg, was hospitalized in our hospital. His condition were ALS and diabetes. He achieved significant improvement after 55 days TCM treatment.
Record of Hospitalization Name: Alsalahi Sex: Male Age: 59 Marital Status: Married Nationality: Yemen Date of Admission: Apr. 15, 2014 Companion: his son First Medical Record Date: Apr. 15, 2014 Time: 10:00 am This 59-year-old man had suffered from movement limitation over his left leg for eight months, accompanied by slight muscle atrophy over his left leg. The patient was hospitalized in our hospital for TCM treatment at 19 pm on April 14, 2014. Essential for Diagnosis:
1. The patient had been suffering from movement limitation over his left leg for eight months, accompanied by slight muscle atrophy over his left leg. He was diagnosed as Type Ⅱ diabetes in 2009. No allergy history to any food or any medicine.
2. When the patient hospitalized in our hospital, he suffered movement limitation over his left foot. He walks with the help of walking stick. Muscles over his left thigh was slightly atrophic. There were pains over his left thigh sometimes. He felt tired and heavy over his whole body, especially his left leg. Movement over his upper limbs were very slow. Muscle jumpings were seen over his four limbs. He did not feel any headache or dizziness. There were no tinnitus or deafness problems. He did not have difficulty in swallowing or speaking. He suffered night sweating. Sleep was not good. He had night urination for 4-5 times per night. Appetite was good. Lower limbs were afraid of cold. 3. T: 36.4°C R: 20 times/minute P: 74 times/minute BP: 125/70 mmHg 4. His spirit activities were normal. There was no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. His neck was soft with no resistance. His chest was symmetrical. Rhythm of his heart was 74 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. His abdomen was soft with no pressing pains and rebound tenderness. There was muscle atrophy over the muscles of his left thigh. His tongue was red with slightly thick and yellowish tongue coating. His pulse was deep and thready. First Diagnosis: TCM: atrophy disease Western medicine diagnosis: ALS and Type Ⅱ diabetes. Treatment strategy and nursing: 1. Routine care of traditional Chinese internal medicine.
2. Grade Ⅱ care.
3. Companion. 4. Diet with low fat and high protein. 5. Herbal tea: one dosage a day and drink twice 6. Acupuncture and massage: once a day 7. Have more medical examination if necessary. Date: Apr. 16, 2014 Time: 10:00 am Dr. Ming, doctor-in-charge, paid a visit to the patient this morning. The patient said he has suffered movement limitation over his left leg for eight months. He walks with the help of walking stick. Muscles over his left thigh was slightly atrophic. There were pains over his left thigh sometimes. He felt tired and heavy over his whole body, especially his left leg. Movements over his upper limbs were very slow. Muscle jumpings were seen over his four limbs. He did not feel any headache or dizziness. There were no tinnitus and deafness problems. He did not have difficulty in swallowing or speaking. He suffered night sweating. Sleep was not good. He had night urination for 4-5 times per night. Appetite was good. Lower limbs were aversion to cold. His tongue was red with slightly thick and yellowish tongue coating. His pulse was deep and thready. Date: Apr. 17, 2014 Time: 10:00 am The patient’s condition was stable today. Feedback of the lab examination: TG 2.22, HDL 0.35, ALT 62, DB 1.4, TP 54, VA 523, CK 783, CK-MB 31, GLU 6.5 Date: Apr. 18, 2014 Time: 10:00 am The patient said he did not suffer sweating during the night. Appetite was good. Sleep was not good. Tiredness and heaviness were changed better. He had night urination for 2-3 times. His pulse was deep and thready. His tongue was slightly pale with thin and white coating. Date: Apr. 21, 2014 Time: 10:00 am The patient said muscle jumpings over the inside of his left thigh were reduced a little. The feeling of tiredness and heaviness over his left leg was reduced. Appetite and sleep were good. His pulse was deep and thready. His tongue was slightly pale with thin and white coating. Date: Apr. 24, 2014 Time: 10:00 am The patient said the strength of his upper limbs was decreased obviously, especially the right hand. He felt slightly shaking over his both hands. Other conditions were the same as before. Date: Apr. 27, 2014 Time: 10:00 am The patient said the strength of his upper limbs was decreased. He felt heavy over his body. Appetite was good. Sleep was good. His tongue was red with thin and white tongue coating. His pulse was deep and thready. Date: May 1, 2014 Time: 10:00 am The patient said the strength of his upper limbs was increased. It was easy for him to lift his hands. He felt more power over his left leg. Date: May 4, 2014 Time: 10:00 am The patient said power of his upper limbs was increasing. Gripping power of his hands increased. Sleep was good. Date: May 7, 2014 Time: 10:00 am The patient said strength of her upper limbs was increasing, but he still felt powerless. He felt muscle jumpings over the muscles of his back and shoulders. He had night urination for 4 times. He was easy to sweat. Date: May 10, 2014 Time: 10:00 am The patient said strength of her upper limbs was increasing slightly. There were muscle jumpings over the muscles of his right back and shoulder. Appetite and sleep were normal. His tongue was slightly red with thin and white tongue coating. His pulse was thready and rapid. Date: Apr. 13, 2014 Time: 10:00 am The patient said strength of her upper limbs was increasing. No more muscle jumpings over his right shoulder. Appetite and sleep were normal. His tongue was slight red with thin and white tongue coating. His pulse was thready and rapid. Date: May 16, 2014 Time: 10:00 am The patient said muscle jumpings over the right side of the body were gone, but there were still some muscle jumpings over his left thigh. Strength of his upper limbs were increased a lot. Appetite and sleep were normal. His tongue was slightly red with thin and white tongue coating. His pulse was thready and rapid. Date: May 22, 2014 Time: 10:00 am The patient said there were muscle jumpings over his right arm and right thigh for 3-4 times per day. When raising his upper limbs, he felt powerless. There were pains over his left thigh. Appetite and sleep were normal. Date: May 25, 2014 Time: 10:00 am The patient’s condition was stable. There were no obvious changes over his conditions. Date: May 28, 2014 Time: 10:00 am The patient complained occasional dizziness. Appetite was normal. There was heavy sensation over his back part. He felt more powerful when lifted his right upper limb. There were slight muscle jumpings over the outside of his right lower limb, but functional movement was better. Check: gripping power, left hand 12.0 Kilos, right hand 5.0 Kilos. The tongue was slightly red with thin and yellowish tongue coating. His pulse was deep, wiry and thready. His condition was improved a lot. Date: June 1, 2014 Time: 10:00 am Today, the patient had good spirit. No more dizziness. Heavy sensation over his lower back was better. Gripping power of his upper limbs was improved. There was no obvious discomfort. His tongue coating was thin and yellowish. His pulse was deep, wiry and thready, but more powerful. Date: June 4, 2014 Time: 10:00 am The patient said there were no obvious changes over the symptoms. His stool, this morning was watery. He had bowel movement for two times. There was no discomfort over his abdomen. Date: June 8, 2014 Time: 10:00 am